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INFECTIOUS   DISEASES 


Copyright,  1918,  by 
D.  Appleton  and  Company 


Printed  in  the  United  States  of  America 


INFECTIOUS  DISEASES 

TYPHOID    FEVER   AND  DYSENTERIES,  CHOLERA  AND 

PARATYPHOID  FEVERS  EXANTHEMATIC  TYPHUS 


SYPHILIS  ABNORMAL  FORMS 

AND  THE  ARMY  OF  TETANUS 

MALARIA 
IN  MACEDONIA 

BY 

H.  VINCENT 

L.  MURATET 

G.  THIBIERGE 

M.  COURTOIS-SUFFIT 

R.  GIROUX 

P.  ARMAND-DELILLE 

P.  ABRAMI 

G.  PAISSEAU 

HENRI  LEMAIRE 


D.    APPLETON    AND    COMPANY 

NEW    YORK    AND    LONDON 
1918 


Copyright,   191S,  by 
D.  Appleton  and  Company 


Printed  in  the  United  States  of  America 


FOREWORD 

The  present  conflict  as  viewed  by  the  medical  man 
emphasizes  several  outstanding  facts.  First  among  these 
is  the  fundamental  truth  that,  despite  the  boundless 
variety  of  surgical  injuries  and  the  essentially  specific 
internal  medical  diseases  of  warfare,  the  established  prin- 
ciples of  surgery  and  medicine  still  govern  the  art  of  the 
proper  practice  of  these  sciences.  The  application  of  these 
principles  quite  regularly  demands  modification  in  order 
to  meet  the  changing  conditions  of  warfare. 

It  is  necessary,  of  course,  that  these  modifications  be 
adequately  "proved  out."  The  first  step  in  this  process 
of  proving  out  consists  in  doing  exactly  what  these  volumes 
of  the  '* Horizon  Collection"  seeji  to  do, — namely,  to 
present  well  coordinated  data  and  conclusions  to  a  broad 
and  critical  audience.  The  series  of  manuals  really  repre- 
sents what  Sir  Alfred  Keogh,  in  his  foreword  to  Hull's 
Surgery  in  War,  characterized  as  a  "stock  taking  of  the 
surgical  position,  to  apportion  value  to  various  methods 
of  treatment,  and  to  obtain  some  appreciation  of  their 
results." 

It  IS  a  privilege  to  be  able  to  prophesy  the  service  that 
these  brochures  will  render  to  the  Medical  Corps  of  the 
United  States  Army  in  its  efforts  to  emulate  the  zeal, 
resourcefulness  and  incomparable  scientific  enthusiasm 
of  our  allied  professional  brethren  in  France  and  England. 

(Signed)  W.  C.  Gorgas, 

Surgeon  General,  U.  S.  A. 


GENERAL   INTRODUCTION 

The  infinite  variety  of  injuries  which  any  war 
presents  to  the  surgeon  gives  to  mihtary  surgery  a 
special  interest  and  importance.  The  special  interest 
and  importance,  in  a  surgical  sense,  of  the  great 
European  War  lies  not  so  much  in  the  fact  that 
examples  of  every  form  of  gross  lesion  of  organs  and 
limbs  have  been  seen,  for  if  we  read  the  older  writers 
we  find  little  in  the  modems  that  is  new  in  this  respect, 
but  is  to  be  found  in  the  enormous  mass  of  clinical 
material  which  has  been  presented  to  us  and  in  the 
production  of  evidence  sufficient  to  eliminate  sources 
of  error  in  determining  important  conclusions.  For 
the  first  time  also  in  any  campaign  the  labours  of 
the  surgeon  and  the  physician  have  had  the  aid  of  the 
bacteriologist,  the  pathologist,  the  physiologist  and 
indeed  of  every  form  of  scientific  assistance  in  the 
solution  of  their  respective  problems.  The  clinician 
entered  upon  the  great  war  armed  with  all  the  re- 
sources which  the  advances  of  fifty  years  had  made 
available.  If  the  surgical  problems  of  modern  war 
can  be  said  not  to  differ  sensibly  from  the  campaigns 
of  the  past,  the  form  in  which  they  have  been  pre- 
sented is  certainly  as  different  as  are  the  methods  of 
their  solution.  The  achievements  in  the  field  of  dis- 
covery of  the  chemist,  the  physicist  and  the  biologist 
have  given  the  military  surgeon  an  advantage  in 
diagnosis  and  treatment  which  was  denied  to  his 
predecessors,  and  we  are  able  to  measure  the  effects 
of  these  advantages  when  we  come  to  appraise  the 
results  which  have  been  attained. 

But  although  we  may  admit  the  general  truth  of 
these  statements  it  would  be  wrong  to  assume  that 
modern  scientific  knowledge  was,  on  the  outbreak  of 
the  war,   immediately  useful  to  those  to   whom  the 

ix 


X  GENERAL  INTRODUCTION 

wounded  were  to  be  confided.  Fixed  principles  existed 
in  all  the  sciences  auxiliary  to  the  work  of  the  surgeon, 
but  our  scientific  resources  were  not  immediately 
available  at  the  outset  of  the  great  campaign  ;  scientific 
work  bearing  on  wound  problems  had  not  been  arranged 
in  a  manner  adapted  to  the  requirements,  indeed  the 
requirements  were  not  fully  foreseen ;  the  workers  in 
the  various  fields  were  isolated,  or  isolated  themselves 
pursuing  new  researches  rather  than  concentrating 
their  powerful  forces  upon  the  one  great  quest. 

However  brilliant  the  triumphs  of  surgery  may  be, 
and  that=  they  have  been  of  surpassing  splendour  no 
one  will  be  found  to  deny,  experiences  of  the  war  have 
already  produced  a  mass  of  facts  sufficient  to  suggest 
the  complete  remodelling  of  our  methods  of  education 
and  research. 

The  series  of  manuals,  which  it  is  my  pleasant  duty 
to  introduce  to  English  readers,  consists  of  trans- 
lations of  the  principal  volumes  of  the  "  Horizon  " 
Collection  which  has  been  appropriately  named  after 
the  uniform  of  the  French  soldier. 

The  authors,  who  are  all  well-known  specialists  in 
the  subjects  which  they  represent,  have  given  a  con- 
cise but  eminently  readable  account  of  the  recent 
acquisitions  to  the  medicine  and  surgery  of  war  which 
had  hitherto  been  disseminated  in  periodical  literature. 

No  higher  praise  can  be  given  to  the  Editors  than  to 
say  that  the  clearness  of  exposition  characteristic  of  the 
French  original  has  not  been  lost  in  the  rendering  into 
English. 

MEDICAL   SERIES 

The  medical  volumes  which  have  been  translated 
for  this  scries  may  be  divided  into  two  main  groups, 
the  first  dealing  with  certain  epidemic  diseases  includ- 
ing syphilis,  which  are  most  liable  to  attack  soldiers, 
and  the  second  with  various  aspects  of  the  neurology 
of  war.  The  last  word  on  Typhoid  Fever,  hitherto 
"  the  greatest  scourge  of  armies  in  time  of  war,"  as 
it  has  been  truly  called,  will  be  found  in  the  mono- 


GENERAL  INTRODUCTION  x\ 

graph  by  MM.  Vincent  and  Muratet  which  contains  a 
full  account  of  recent  progress  in  bacteriology  and 
epidemiology  as  well  as  the  clinical  features  of  typhoid 
and  paratyphoid  fevers.  The  writers  combat  a  belief 
in  the  comparatively  harmless  nature  of  paratyphoid 
and  state  that  in  the  present  war  haemorrhage  and 
perforation  have  been  as  frequent  in  paratyphoid  as 
in  typhoid  fever.  In  their  chapter  on  diagnosis  they 
show  that  the  serum  test  is  of  no  value  in  the  case 
of  those  who  have  undergone  anti -typhoid  or  anti- 
para  typhoid  vaccination  and  that  precise  information 
can  be  gained  by  blood  cultures  only.  The  relative 
advantages  of  a  restricted  and  liberal  diet  are  dis- 
cussed in  the  chapter  on  treatment,  which  also  con- 
tains a  description  of  serum -therapy  and  vaccine - 
therapy  and  the  general  management  of  the  patient. 

Considerable  space  is  devoted  to  the  important 
question  of  the  carrier  of  infection.  A  special  chapter 
is  devoted  to  the  prophylaxis  of  typhoid  fever  in  the 
army.  The  work  concludes  with  a  chapter  on  pre- 
ventive inoculation  in  which  its  value  is  conclusively 
proved  by  the  statistics  of  all  countries  in  which  it  has 
been  employed. 

MM.  Vincent  and  Muratet  have  also  contributed  to 
the  series  a  work  on  Dysentery,  Cholera  and  Typhus 
which  will  be  of  special  interest  to  those  whose  duties 
take  them  to  the  Eastern  Mediterranean  or  Mesopo- 
tamia. The  carrier  problem  in  relation  to  dysentery 
and  cholera  is  fully  discussed,  and  special  stress  is  laid 
on  the  epidemiological  importance  of  mild  or  abortive 
cases  of  these  two  diseases. 

In  their  monograph  on  The  Abnormal  Forms  of 
Tetanus,  MM.  Courtois-Suffit  and  Giroux  treat  of  those 
varieties  of  the  disease  in  which  the  spasm  is  confined 
to  a  limited  group  of  muscles,  e.  g.  those  of  the  head, 
or  one  or  more  limbs,  or  of  *the  abdomino-thoracic 
muscles.  The  constitutional  symptoms  are  less  severe 
than  in  the  generalised  form  of  the  disease,  and  the 
prognosis  is  more  favourable. 

The  volume  by  Dr.  G.  Thibierge  on  Syphilis  in  the 


xii  GENERAL  INTRODUCTION 

Army  is  intended  as  a  vade-mecum  for  medical  officers 
in  the  army. 

Turning  now  to  the  works  of  neurological  interest, 
we  have  two  volumes  dealing  with  lesions  of  the  peri- 
pheral nerves  by  Mme.  Atanassio  Benisty,  who  has 
been  for  several  years  assistant  to  Professor  Pierre 
Marie  at  La  Salpetriere.  The  first  volume  contains 
an  account  of  the  anatomy  and  physiology  of  the 
peripheral  nerves,  together  with  the  symptomatology 
of  their  lesions.  The  second  volume  is  devoted  to  the 
prognosis  and  treatment  of  nerve  lesions. 

The  monograph  of  MM.  Babinski  and  Froment  on 
Hysteria  or  Pithiatism  and  Nervous  Disorders  of  a 
Reflex  Character  next  claims  attention.  In  the  first 
part  the  old  conception  of  hysteria,  especially  as  it 
was  built  up  by  Charcot,  is  set  forth,  and  is  followed 
by  a  description  of  the  modern  conception  of  hysteria 
due  to  Babinski,  who  has  suggested  the  substitution 
of  the  term  "  Pithiatism,"  i.  e.  a  state  curable  by 
persuasion,  for  the  old  name  hysteria.  The  second 
part  deals  with  nervous  disorders  of  a  reflex  character, 
consisting  of  contractures  or  paralysis  following  trau- 
matism, which  are  frequently  found  in  the  neurology 
of  war,  and  a  variety  of  minor  symptoms,  such  as 
muscular  atrophy,  exaggeration  of  the  tendon  reflexes, 
vasomotor,  thermal  and  secretory  changes,  etc.  An 
important  section  discusses  the  future  of  such  men, 
especially  as  regards  their  disposal  by  medical  boards. 
An  instructive  companion  volume  to  the  above  is 
to  be  found  in  the  monograph  of  MM.  Roussy  and 
Lhermitte,  which  embodies  a  description  of  the  psycho- 
neuroses  met  with  in  war,  starting  with  elementary 
motor  disorders  and  concluding  with  the  most  complex 
represented  by  pure  psychoses. 

SURGICAL    SERIES 

When  the  present  war  began,  surgeons,  under  the' 
influence  of  the  immortal  work  of  Lister,  had  for 
more  than  a  quarter  of  a  century  concerned  themselves 


GENERAL  INTRODUCTION  xiii 

almost  exclusively  with  elaborations  of  technique  de- 
signed to  shorten  the  time  occupied  in  or  to  improve 
the  results  obtained  by  the  many  complex  operations 
that  the  genius  of  Lister  had  rendered  possible.  The 
good  behaviour  of  the  wound  was  taken  for  granted 
whenever  it  was  made,  as  it  nearly  always  was,  through 
unbroken  skin,  and  hence  the  study  of  the  treatment 
of  wounds  had  become  largely  restricted  to  the  study 
of  the  aseptic  variety.  Septic  wounds  were  rarely 
seen,  and  antiseptic  surgery  had  been  almost  for- 
gotten. Very  few  of  those  who  were  called  upon  to 
treat  the  wounded  in  the  early  autumn  of  1914  were 
familiar  with  the  treatment  of  grossly  septic  com- 
pound fractures  and  wounded  joints,  and  none  had 
any  wide  experience.  To  these  men  the  conditions  of 
the  wounds  came  as  a  sinister  and  disheartening  reve- 
lation. They  were  suddenly  confronted  with  a  state 
of  affairs,  as  far  as  the  physical  conditions  in  the 
wounds  were  concerned,  for  which  it  was  necessary  to 
go  back  a  hundred  years  or  more  to  find  a  parallel. 

Hence  the  early  period  of  the  war  was  one  of  earnest 
search  after  the  correct  principles  that  should  be 
applied  to  the  removal  of  the  unusual  difficulties  with 
which  surgeons  and  physicians  were  faced.  It  was 
necessary  to  discover  where  and  why  the  treatment 
that  sufficed  for  affections  among  the  civil  population 
failed  when  it  was  applied  to  military  casualties,  and 
then  to  originate  adequate  measures  for  the  relief  of 
the  latter.  For  many  reasons  this  was  a  slow  and 
laborious  process,  in  spite  of  the  multitude  of  workers 
and  the  wealth  of  scientific  resources  at  their  disposal. 
The  ruthlessness  of  war  must  necessarily  hamper  the 
work  of  the  medical  scientist  in  almost  every  direction 
except  in  that  of  providing  him  with  an  abundance  of 
material  upon  which  to  work.  It  limits  the  opportunity 
for  deliberate  critical  observation  and  comparison  that 
is  so  essential  to  the  formation  of  an  accurate  estima- 
tion of  values  ;  it  often  compels  work  to  be  done  under 
such  high  pressure  and  such  unfavourable  conditions 
that  it  becomes  of  little  value  for  educative  purposes. 


xiv  GENERAL  INTRODUCTION 

In  all  the  armies.,  and  on  all  the  fronts,  the  pressure 
caused  by  the  unprecedented  number  of  casualties  has 
necessitated  rapid  evacuation  from  the  front  along 
lines  of  communication,  often  of  enormous  length,  and 
this  means  the  transfer  of  cases  through  many  hands, 
with  its  consequent  division  of  responsibility,  loss  of 
continuity  of  treatment,  and  absence  of  prolonged 
observation  by  any  one  individual. 

In  addition  to  all  this,  it  must  be  remembered  that 
in  this  war  the  early  conditions  at  the  front  were  so 
uncertain  that  it  was  impossible  to  establish  there  the 
completely  equipped  scientific  institutions  for  the  treat- 
ment of  the  wounded  that  are  now  available  under 
more  assured  circumstances,  and  that  progress  was 
thereby  much  hampered  until  definitive  treatment 
could  be  undertaken  at  the  early  stage  that  is  now 
possible. 

But  order  has  been  steadily  evolved  out  of  chaos 
and  many  things  are  now  being  done  at  the  front  that 
would  have  been  deemed  impossible  not  many  months 
ago.  As  general  principles  of  treatment  are  estab- 
lished it  is  found  practicable  to  give  effect  to  them  to 
their  full  logical  extent,  and  though  there  are  still 
man}^  obscure  points  to  be  elucidated  and  many 
methods  in  use  that  still  call  for  improvements,  it  is 
now  safe  to  say  that  the  position  of  the  art  of  military 
medicine  and  surgery  stands  upon  a  sound  foundation, 
and  that  its  future  may  be  regarded  with  confidence 
and  sanguine  expectation. 

The  views  of  great  authorities  who  derive  their 
knowledge  from  extensive  first-hand  practical  expe- 
rience gained  in  the  field,  cannot  fail  to  serve  as  a 
most  valuable  asset  to  the  less  experienced,  and  must 
do  much  to  enable  them  to  derive  the  utmost  value 
from  the  experience  which  will,  in  time,  be  theirs. 
The  series  covers  the  whole  field  of  war  surgery  and 
medicine,  and  its  predominating  note  is  the  exhaus- 
tive, practical  and  up-to-date  manner  in  which  it  is 
handled.  It  is  marked  throughout  not  only  by  a 
wealth  of  detail,  but  by  clearness  of  view  and  logical 


GENERAL   INTRODUCTION  xv 

sequence  of  thought.  Its  study  will  convince  the 
reader  that,  great  as  have  been  the  advances  in  all 
departments  in  the  services  during  this  war,  the  ])ro- 
gress  made  in  the  medical  branch  may  fairly  challenge 
comparison  with  that  in  an 3^  other,  and  that  not  the 
least  among  the  services  rendered  by  our  great  Ally, 
France,  to  the  common  cause  is  this  brilliant  contiibu- 
tion  to  our  professional  knowledge. 

A  glance  at  the  list  of  surgical  works  in  the  series 
will  show  how  completely  the  ground  has  been  covered. 
Appropriately  enough,  the  series  opens  with  the  volume 
on  The  Treatment  of  Injected  Wounds,  by  A.  Carrel  and 
G.  Dehelly.  This  is  a  direct  product -of  the  war  which. 
in  the  opinion  of  many,  bids  fair  to  become  epoch- 
making  in  the  treatment  of  septic  wounds.  It  is 
peculiar  to  the  war  and  derived  directly  from  it,  and 
the  work  upon  which  it  is  based  is  as  fine  an  example 
of  correlated  work  on  the  part  of  the  chemist,  the 
bacteriologist  and  the  clinician  as  could  well  be  wished 
for.  This  volume  will  show  many  for  the  first  time 
what  a  precise  and  scientific  method  the  "  Carrt^l 
treatment  "  really  is. 

The  two  volumes  by  Prof.  Leriche  on  Fractures  con- 
tain the  practical  application  of  the  views  of  the  great 
Lyons  school  of  surgeons  with  regard  to  the  treatment 
of  injuries  of  bones  and  joints.  Supported  as  they 
are  by  an  appeal  to  an  abundant  clinical  experience, 
they  cannot  fciil  to  interest  English  surgeons,  and  to 
prove  of  the  greatest  value.  It  is  only  necessary  to 
say  the  Wounds  of  the  Abdomen  are  dealt  with  by 
Dr.  Abadie,  Wounds  of  the  Vessels  by  Prof.  Sencert, 
Wounds  of  the  Skull  and  Brain  by  MM.  Chatelin  and 
De  Martel,  and  Localisation  and  Extraction  of  Pro 
jectiles  by  Prof.  Ombredanne  and  R.  Ledoux-Lebard, 
to  prove  that  the  subjects  have  been  allotted  to  very 
able  and  experienced  exponents. 

Alfred  Keoch. 


CONTENTS 


SECTION  I 


TYPHOID  FEVER  AND  PARATYPHOID  FEVER 

BY 

H.  Vincent  and  L.  Muratet 

PART  I 

CLINICAL  SURVEY 

PAGE 

Chapter  L  Clinical  Characters  of  Typhoid 

Fever 3 

Ordinary  Forms      3 

Typhoid  Fever  according  to  Age   .  12 

Termination  of  Typhoid  Fever      .  20 

Relapses 23 

Sequelae  of  Typhoid  Fever      ...  24 

Chapter         II.  Clinical  Characters  of  Typhoid 

Fever — continued 26 

Analysis  of  Symptoms  and  Com- 
plications According  to 
their  Anatomical  Position  .      26 

Digestive  System      26 

Spleen 37 

Respiratory  System      38 

Circulatory  System      41 

Veins — Typhoid  Phlebetis,  Throm- 
bo-Phlebitis,  Phlegmasia  Alba 

Dolens 43 

Pulse  and  Temperature 49 

xvii 


XVI 11 


CONTENTS 

PAGE 

Nervous  System 58 

Special  Senses 65 

Liver  and  Gall  Bladder 66 

Peritoneum 68 

Urinary  System 69 

Diazo-Reaction 71 

Various  Glands  and  Systems      .    .  72 

Muscular  System 74 

Osseous  System 75 

Skin 76 

Chapter        III.  Clinical  Characters  of  Paraty- 
phoid Ff:vER  A  AND  B      ...  80 

Incubation  Period 81 

Temperature 85 

Various  Forms       9*2 

IV.  Diagnosis     96 

Clinical  Diagnosis 96 

Diagnosis  by  Laboratory  Methods  107 
Study  of  the  more  or  less  Specific 

Humoral 118 

V.  Treatment  of  Typhoid  and  Para- 
typhoid Fevers 123 

Hygiene  of  the  Typhoid  Patient   .  123 

Diet 128 

Antipyretic  Measures 1 33 

Various  Modes  of  Treatment   .    .    .  141 
Treatment    of    Complications    in- 
volving the  digestive  system   .    .  143 
Specific  Therapy 148 


Chapter 


Chapter 


CONTENTS 


XIX 


PART  II 

EPIDEMIOLOGY  AND  PROPHYLAXIS  OF 

TYPHOID  AND  PARATYPHOID 

FEVERS 

PAGE 

Chapter  VI.  Epidemiology  of  Typhoid  Fever  156 
Frequency  of  the  Disease  ....  156 
TyphoidFever  in  WarTime    ...    159 

Chapter       VII.   Etiology     of     Typhoid     Fever. 

Favoring  Causes 164 

Chapter     VIIL  Etiology  of  Typhoid  Fever    .    .175 
Tlie  Human  Factor  .......    175 

Determining  Causes 175 

Chapter        IX.  Etiology    of    Typhoid    Fever — 

continyed 186 

The  Human  Factor  .        186 

Role  of  Carriers 187 

Chapter         X.  The  Principal  Modes  of  Direct 

Transmission    of    the    Ty- 
phoid Bacillus 198 

Chapter        XL  Indirect  Contagion  by  Patients 

OR  Carriers      . 204 

Inert  Factors  of  Transmission   of 

the  Typhoid  Bacillus     ....   204 

Role  of  Drinking  Water  and  other 

Liquid  Foods 210 

Role  of  Flies 217 

Chapter      XIL  Character    and    Evolution    of 

Epidemics      According      to 
their  Causes 220 


XX  CONTENTS 


PAOB 


Chapter     XIII.  Prophylaxis  of  Typhoid  Fever. 

Prophylaxis     of    Favoring 
Causes 225 

Chapter     XIV.  Specific  Prophylaxis  of  Typhoid 

Fever 231 

Prophylaxis  with  Regard  to  Car- 
riers      234 

Water  and  other  Beverages,  Food, 

Fhes,etc 236 

Chapter       XV.  Prophylaxis    of  Typhoid   Fever 

IN  THE  Army      242 

Chapter     XVI.  Etiology    and    Prophylaxis    of 

Paratyphoid  Fevers  .  .  .  253 
Etiology  of  Paratyphoid  Fevers  .  256 
Prophylaxis  of  Paratyphoid  Fevers  261 

Chapter    XVII.  Anti-typhoid    and     Anti-paraty- 
phoid Vaccination      ....   263 

Mixed  Vaccination 268 

The  Technique  of  Injecting      ...   270 


SECTION  II 
DYSENTERIES 

BY 

H.  Vincent  and  L.  Muratet 

PART  I 
CLINICAL  STUDY 

Chapter  I.  Symptomatology 295 

Bacillary  Dysentery 298 

The   Clinical   Forms   of   Bacillary 

Dysentery      300 


Chapter 


Chapter 


CONTENTS  xxi 

PAGE 

Complications        304 

Amebic  Dysentery    . 305 

Complications .    306 

Dysenteries     caused     by     Various 

Etiological  Agents 308 

II.  The  Diagnosis  OF  Dysentery      .    311 
Diagnosis  of  the  Dysenteric  Syn- 
drome      311 

Diagnosis    of    the    Nature    of    the 

Disease 313 

III.  The  Treatment  of  Dysentery      324 


PART  II 

EPIDEMIOLOGY  AND  PROPHYLAXIS  OF 
DYSENTERY 

Chapter        IV.  Epidemiology  of  Bacillary  Dys- 
entery   335 

Dysentery  in  the  Army     .....    337 

Chapter  V.  Etiology .    343 

The  Predisposing  Causes  of  Bacil- 
lary Dysentery       343 

The  Determining  Causes  of  Bacil- 
lary Dysentery      345 

Indirect  Contagion .   349 

The  Spread  of  Epidemics  .    .    .    .   357 

Chapter        VI.  Epidemiology  of  Amebic  Dysen- 
tery        359 

Chapter      VII.  Prophylaxis  of   Bacillary  and 

Amebic  Dysenteries      .    .    .    309 


XXll 


CONTENTS 


ASIATIC  CHOLERA 

PART  I 
CLINICAL  STUDY 

PAGB 

Chapter      VIII.  Symptomatology 377 

Accidents  and  Complications       .    .   390 

Relapses,  Recurrence 392 

Clinical  Forms ".392 

Chapter        IX.  diagnosis        396 

Chapter  X.  Treatment         402 


PART  II 


EPIDEMIOLOGY  AND  PROPHYLAXIS  OF 
CHOLERA 

Chapter        XL  Historical 407 

Chapter      XII.  Etiology  of  Cholera.        Favor- 
ing Causes    411 

The  Determining  Causes  of  Cholera  414 
Carriers  of  the  Cholera  Vibrios     .    .   417 

Chapter    XIII.  Etiology  of    Cholera — continued  ^^\ 
The  Modes  of  Propagation  of  the 

Cholera  Vibrio 424 

Chapter       XIV.  Prophylaxis  of  Cholera     .    .    .   436 
The  Prophylaxis    of    Cholera    on 

Warships 437 

The  Microbic  Prophylaxis  ....   438 
The  Specific  Prophylaxis      ....   446 


CONTENTS  xxiii 

EXANTHEMATIC  TYPHUS 
TART  I 
CLINICAL  STUDY 

PAGE 

Chapter       XV.    Symptomatology 453 

Complications        460 

Clinical  Forms 461 

Chapter     XVI.  Diagnosis       463 

Chapter   XVII.  Treatment 468 

PART  II 

EPIDEMIOLOGY  AND  PROPHYLAXIS  OF 
TYPHUS 

Chapter  XVIII.  History  ahd  Geographical  Dis- 
tribution       471 

Chapter     XIX.  Etiology  of  Typhus 478 

Predisposing  Causes 478 

Chapter       XX,  Etiology  of  Typhus — continued   .   48-2 
The  Determining  Causes      ....   48*2 

Chapter     XXI.  The  Prophylaxis  of  Typhus     .    .   493 
The  Campaign  against  Lice    .    .    .   495 

SECTION  III 
SYPHILIS  AND  THE  ARMY 

BY 

G.  Thibierge 

Chapter  I.  Frequency   of  Syphilis  in  the 

Army      503 

Chapter  II.  Origin  of  Syphilitic  Contagion 

in  the  Army      509 


xxiv  CONTENTS 


PAGE 


Chapter        III.  Syphilis  as  a  National  Danger  .     518 
Syphilis    amongst   the   Civil   Popu- 
lation since  the  Beginning  of 

Hostilities       518 

The  Social  Consequences  of  Syph- 
ilis amongst  Soldiers      ....    523 

Chapter        IV.  Symptoms  and  Diagnosis  of  the 

Syphilitic    Lesions    most 
Commonly  Observed  in  the 

Army 536 

Syphilitic  Chancre 536 

Diagnostic  Elements  of  Syphilitic 
Chancre      545 

Diagnostic  Importance  of  the 
Objective  Sign 545 

Diagnostic  Value  of  the  Signs 
drawn  from  the  Evolution  of 
the  Chancre 547 

Signs  drawn  from  the  Patient\s 
Antecedents,  or  from  the  Ap- 
pearance of  Symptoms  of  Sec- 
ondary Syphilis 547 

Indications  supplied  by  Labora- 
tory Researches 549 

Research  for  the  Parasite  of 
Syphilis       549 

Researches  for  the  Fixation  of 
the      Complement      (Wasser- 

mann  Reaction) 554 

Differential  Diagnosis  of  Syph- 
ilitic Chancre 557 

Extragenital  Chancres     ....   568 
Secondary  Syphilis .   572 

Cutaneous  Lesions 573 


CONTENTS  XXV 

PAGE 

Syphilitic  Alopecia 581 

Lesions  of  the  Nails       582 

Lesions    of    the    Mucous    Mem- 
branes       582 

Lesions  of  the  Pharynx     ....  584 

Visceral  Affections 585 

Generalities  on  Tertiary  Syphilis  586 

Chapter  V.  Treatment  of  Syphilis       .    .    .    .591 

The     Special     Conditions     of    the 
Treatment  of  Syphilis  in  the 

Army       591 

Mercury     . 593 

Mercurial    Medication    by    In- 
gestion     594 

Mercurial  Medication  per  Rec- 
tum      599 

Endermic      Administration      of 
Mercury 600 

Intramuscular  Administration  of 
Mercury 600 

Technique  of  Intramuscular  In- 
jections  601" 

Intravenous    Administration    of 

Mercury .   608 

Arsenic 612 

Arsenobenzol 612 

Novarsenobenzol       615 

Vehicle  of  Injections  of  Novarse- 
nobenzol      616 

Effects   of   Novarsenobenzol   on 
Syphilitic  Manifestations     .    ,619 
In  what  Doses  should  Novarseno- 
benzol be  Injected? 625 

Periodicity  of  the  Injections    .    .   628 


XXVI 


Chapter 


Chapter 


Chapter 


CONTENTS 

PAOE 

After  Effects  of  Concentrated  In- 
jections of  Novarsenobenzol   .   6-28 
Serious  Accidents  of  Arsenohen- 

zol  and  Novarsenobenzol      .    .    630 
Other  x\rsenical  Preparations       .    636 
Association  of  Mercury  and  Arsenic  638 
Scheme  of  Treatment  of  SyphiHs  in 
the  Army  at  Different  Periods 

of  Infection 641 

Cliancral  Period 64*2 

Secondary  Period      644 

Continued  Treatment       ....   649 

VI.  Technique    of   Intravenous    In- 
jections      65l2 

Instruments 652 

Mode  of  Operation 6.55 

Operative  Accidents     ......   661 

Precautions  to  be  taken  after  In- 
travenous Injections  of  Cyanid 

of  Mercury 663 

Precautions  to  be  taken  after  In- 
travenous Injections  of  Novar- 
senobenzol       664 

VII.  Hygiene   of  Syphilitic   Soldiers  666 
Prophylaxis 669 

VIII.  Necessary  Precautions  for  Pre- 
venting the  Transmission  of 
Syphilis  by  Infected  Men      669 
Isolation  of  Syphilitic  Carriers  of 

Contagious  Lesions 670 

Medical  Inspection 671 

Syphilitics  and  Hospital  Treatment  673 
Post  -  hospital    Treatment    and 

Supervision 679 


CONTENTS  xxvii 


PAGR 


Measures  for  Preventing  Healthy 

Men  from  Contracting  Syphilis  682 

Instruction  of  Men  with  Regard  to 

Venereal  Danger BS^Z 

Personal  Precautions 688 

Creation  of  Centres  for  the  Treat- 
ment of  Syphilis  amongst  the 
Civil  Population 690 

The  Supervision  of  Prostitution     .    694 

SECTION  IV 
ABNORMAL  FORMS  OF  TETANUS 

BY 
M.  COURTOIS  SUFFIT  AND  R.  GiROUX 

PART  I 

THE  KNOWN  ATYPIC  FORMS  OF  TETANUS 

Chapter  I.  Splanchnic  Tp:tanus       708 

Etiology,    Frequency,    Age    and 

Sex      714 

Clinical  Survey      715 

Individual  Signs  of  Cephalic  Te- 
tanus with  Facial  Paralysis      .  717 
Development  and  Prognosis    .    .  724 
Cephalic   Tetanus    with    Ophthal- 
moplegia           729 

History 729 

Etiology 730 

Clinical  History 731 

Cephalic  Tetanus  with  Paralysis  of 

the  Hypoglossal     ......  742 

Unilateral  Tetanus   .......  743 


xxviii  CONTENTS 

PART  II 
PARTIAL  TETANUS  OF  THE  LIMBS 

PAGE 

Chapter  I.  Observations       745 

Chapter         IL  Historical 780 

Chapter       III.  Monoplegic  Form 783 

Period  of  Incubation 783 

Period  of  Onset      785 

Period  of  Acme      790 

Diagnosis        -.  796 

Chapter        IV.  Paraplegic  Form 805 

Symptomatology       805 

Diagnosis       809 

Chapter  V.  Localized  Tetanus  of  the  Ab- 

domino-Thoracic  Type      .    .811 

Chapter        VI.  Attenuated    Forms   with    Slow 

Development  and  Prolonged 
Incubation 817 

Chapter      VII.  Etiology  and  Pathogenesis     .    .  820 

Etiology 820 

Frequency      ^20 

Cause      821 

Tetanus  Toxin 826 

Method  of  Preparation 826 

Nature  and  Properties  of  the  Toxin  826 

Mode  of  Action  of  the  Toxin    .    ..   .  827 

Pathogenesis      834 

Chapter     VIII.  Development  and  Prognosis  .    .   837 

Development 837 

Prognosis        840 

Chapter        IX.  Treatment        845 

Prophylaxis        845 


CONTENTS  xxix 

PAGE 

Local  Treatment 846 

Preventive  Serotherapy   ....   S5'2 

Curative  Treatment 871 

Antitoxic  Treatment 880 

Symptomatic  Treatment     .    .    .   887 
Sulphate  of  Magnesium   ....    894 

Conclusions        907 

Summary    of    the     Forms     of 

Tetanus      913 

Editorial  Note 920 

Bibliography 927 


SECTION  V 
MALARIA  IN  MACEDONIA 

BY 

P.    Armand-Delille,    p.    Abrami,    G.    Paisseau,    and 
Henry  Lemaire 

Chapter  I.  Parasitology 939 

Chapter         II.  Clinical  Study 949 

Chapter       III.  Syndromes  of  the  First   Inva- 
sion of  Paludism     951 

Syndrome  of  Febrile  Gastric  De- 
rangement       951 

Malarial  Continued  Fever  of  Ty- 
phoid Character 954 

Attenuated  Form  of  Invasion,  Fe- 
brile Malaise,  and  Fatigue  .    .   957 
Chapter        IV.  Period  of  Relapses  in  Primary 

Paludism 960 

Temperature   Curve   in   Periods 

of  Relapses  and  second  attacks  962 
Syndromes  of  Visceral  Localisa- 
tion          ...   968 


XXX 


CONTENTS 


PACE 

969 
974 


978 


Chapter 


V. 


980 
982 
988 
985 
987 
988 
989 
998 

1005 


Anemic  Syndromes 

(lastro-Hepatic  Syndromes     .    . 
Syndrome    of    Acute    and    Sub- 
acute Suprarenal  Insufficiency 
Intestinal    and    Peritoneal    Syn- 
dromes          

Peritoneal  Syndrome  .  .  . 
Syndrome  of  Acute  Cachexia 
Pulmonary  Syndrome  .  . 
Cardio-Vascular  Syndromes 
Urinary  Syndromes  .  .  . 
Nervous  jNIanifestations 
Ocular  Com])lications  .  .  . 
Seconoary  Paludism  .  .  . 
Principal  Types  of  Temperature 

Curves .      1008 

Clinical  Syndromes   .    .    .    .    .    .1011 

IJilious  Hemoglobinuric  Fever   .  1012 
Association  with  Other  Infec- 
tions        1016 

Typhoid   Fever 1016 

Dysentery 1016 

Recurrent  Fever 1017 

Chapter       VIL  Parasitological  Diagnosis      .    .1018 
Directions  for  using  Tribondeau's 

Bi-easinate 1^*^^ 

Diagnostic  Characters  of  Hema 

tozoa 1025 

Plasmodium  Vivax   ....  1025 
Plasmodium         Falciparum 

(Precox)      1029 

Plasmodium  Malariae       .    .1081 

Chapter     VIII.  Treatment        1^'55 

Primary  Paludism 1035 

Period   of   Relapses   and   second 

attacks        1048 

Secondary  Paludism 1049 


Chapter        VI. 


SECTION  I 

TYPHOID    FEVER    AND 
PARATYPHOID  FEVERS 


TYPHOID    FEVER 
AND    PARATYPHOID    FEVERS 

FIRST   PART 
CLINICAL    STUDY 

Few  diseases  have  benefited  so  much  from  laboratory 
research  as  typhoid  fever.  The  discovery  of  the 
specific  bacillus  and  of  its  presence  in  the  blood  before 
the  appearance  of  the  earliest  symptoms,  has  modified 
our  ideas  of  the  etiology  and  pathogeny  of  this  affection. 
The  narrow  limits  within  which  it  had  been  enclosed 
have  been  extended.  We  should  no  longer  regard  it 
as  a  purely  intestinal  affection  as  did  Louis,  Chomel, 
Trousseau,  Bretonneau,  Murchison,  Grisolle,  Jaccoud, 
etc.  It  represents  the  secondary  localisation  of  a 
general  affection  produced  by  a  specific  bacillus.  It 
is  only  a  variety — the  most  frequent  one,  it  is  true — 
of  typhoid  septicaemia,  "  in  the  course  of  which  dis- 
orders of  the  digestive  system,  important  as  they  are, 
are  far  from  representing  the  principal  symptom  of  the 
disease  "  (H.  Roger). 

It  is  just  this  septicsemic  character  of  typhoid  fever 
which  can  explain  the  abundance  of  its  symptoms. 
On  a  fairly  uniform  substratum  of  general  and  nervous 
clinical  signs  a  great  variety  of  morbid  phenomena 
develops,  which  in  turn  are  due  to  some  remarkable 
localisation  of  the  bacillus,  e.  g.  meningitis,  or  to  the 
predominance  of  one  particular  symptom  or  another, 
or  to  the  insidious  or  unexpected  development  of  a 
secondary  infection,  the  clinical  expression  of  which  is 


2     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

superimposed  upon  and  confounded  with  the  signs 
pecuhar  to  typhoid  fever. 

We  may  add  that  it  is  above  all  others  a  disease 
full  of  surprises,  and  one  in  which  sudden  collapse  of 
organic  resistance  occurs  when  it  is  least  to  be  expected. 

The  result  is  that  there  is  some  difficulty  in  including 
in  a  single  description  a  complete  account  of  all  the 
features  of  typhoid  fever. 

In  our  endeavour  to  succeed  in  giving  as  clear  and 
complete  a  description  as  possible,  the  symptoms  of 
typhoid  fever  have  been  discussed  in  this  work  accord- 
ing to  the  following  plan. 

The  first  chapter  contains  a  comprehensive  survey 
of  the  clinical  characters  of  the  most  frequent  form 
of  typhoid  fever. 

The  principal  clinical  types  are  then  dealt  with 
individually  in  a  special  study. 

Finally,  with  the  object  of  completing  the  necessarily 
succinct  portions  of  the  previous  description,  each  of 
the  principal  symptoms  and  their  varieties  are  dis- 
cussed according  to  their  anatomical  localisation. 

This  last  clinical  chapter  is,  therefore,  the  necessary 
complement  of  the  previous  chapters. 


CHAPTER  I 

CLINICAL   CHARACTERS    OF   TYPHOID    FEVER  : 
ORDINARY   FORMS 

The  clinical  forms  of  typhoid  septicaemia  with  an 
intestinal  localisation  are  multiple,  but  are  only 
variants  of  one  particular  form,  viz.  typical  typhoid 
fever  of  moderate  intensity.  From  the  clinical  point 
of  view  we  may  adopt  the  division  into  four  periods, 
incubation,  invasion  or  onset,  height  of  the  disease  and 
defervescence.  This  division  is  based  on  the  course 
of  the  temperature,  since  it  is  the  temperature  which 
is  the  chief  guide  to  treatment  throughout  the  disease, 
and  regulates  the  hygiene  of  convalescence.  The 
temperature  enables  us  to  follow  the  course  of  the 
disease  and  frequently  to  foretell  complications  or 
improvement. 

Incubation. — As  a  rule  it  is  impossible  to  determine 
the  onset  of  the  infection  and  the  time  which  elapses 
between  this  onset  and  the  first  symptoms.  In  the 
great  majority  of  cases,  however,  the  duration  of  the 
incubation  of  typhoid  fever  is  fourteen,  sixteen  or 
twenty  days. 

Under  certain  circumstances  the  incubation  period 
is  much  longer,  and  may  last  from  twenty  to  forty 
days  (Jaccoud,  Apert). 

In  a  case  of  laboratory  infection,  typhoid  fever 
developed  in  forty  days  (Vincent). 

Epidemiological  observations  also  furnish  numerous 
instances  of  long  incubation  periods.  One  may  see 
cases  of  typhoid  fever  breaking  out  at  intervals  ranging 
from  two  to  four  or  five  weeks,  without  any  inter- 
current cause  for  infection  having  intervened. 

3 


4    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

This  latent  period  of  incubation  is,  as  a  rule,  un- 
eventful. No  sign  reveals  the  infection  until  the  day 
when  it  is  manifested  by  malaise,  headache,  digestive 
disturbance,  and  a  rise  of  temperature  with  or  without 
shivering.  This  combination  of  symptoms,  however 
ill -developed  they  may  be,  should  be  looked  on  with 
suspicion,  especially  during  an  epidemic.  In  the  course 
of  the  latent  period  of  the  disease  a  slight  rise  of 
temperature  may  be  noted,  the  thermometer  may 
register  99-0°,  99-4°  or  99-8°  ¥.,  either  in  the  morning, 
which  is  rare,  or  at  night,  which  is  more  frequent. 
In  practice  and  in  cases  of  possible  infection  these 
slight  rises  of  temperature  should  be  looked  for  method- 
ically and  systematically.  They  indicate  the  invasion 
of  the  organism  by  the  typhoid  bacillus,  and  at  this 
moment  it  is  possible  to  fmd  the  pathogenic  micro- 
organism in  cultures  of  the  blood. 

Period  of  Invasion,  or  Onset. — In  most  cases 
the  invasion  takes  place  gradually,  and  the  onset  can 
only  be  determined  retrospectively  by  questioning  the 
patient. 

The  information  so  obtained  is  sometimes  so  in- 
definite that  the  doctor  still  feels  in  doubt,  and  has  to 
reckon  the  onset  of  the  disease  from  the  day  when  the 
patient  took  to  bed. 

An  individual  who  usually  enjoys  good  health 
complains  of  having  been  out  of  sorts  for  several  days. 
He  feels  tired  and  unsteady  in  his  legs,  he  suffers  from 
giddiness  and  tinnitus.  His  head  feels  heavy ;  all 
mental  or  physical  exertion  has  become  difficult,  if  not 
actually  painful  and  distasteful.  He  is  continually 
wanting  to  sleep,  although  at  night  his  sleep  is  dis- 
turbed and  he  is  constantly  waking  up.  He  has  re- 
tained his  clearness  of  mind  and  his  memorj?^,  but  when 
he  speaks  or  answers  questions  put  to  him  he  does  so 
with  a  certain  effort.  He  complains  of  a  slight  pain 
in  the  lumbar  region  and  his  limbs.  The  appetite  is 
lost,  and  there  is  a  bitter  taste  in  the  mouth.  The  sight 
or  smell  of  food  sometimes  causes  nausea.  The  patient 
is  constipated  at  first.     The  constipation  is  followed 


CLINICAL   CHARACTERS   OF    TYPHOID   FEVER    5 

by  an  ochre-coloured  diarrhoea  (four  to  five  stools  in 
the  twenty-four  hours),  without  colic.  There  is  slight 
epistaxis.  The  urine  is  scanty.  The  skin  is  hot,  the 
temperature  is  about  100" 4°  or  102-2°,  the  pulse  quick, 
110  to  the  minute.  The  features  are  drawn,  the  com- 
plexion slightly  yellow,  the  cheeks  red  and  the  lips  dry. 
The  tongue  is  covered  with  a  whitish  coating  and  is 
red  at  the  edges.  The  abdomen  is  slightly  distended. 
On  palpation  one  generally  finds  some  tenderness 
and  gurghng  in  the  right  ihac  fossa.  Pressure  upon 
the  epigastrium,  as  a  rule,  causes  pain  at  the  onset  of 
the  disease.  The  gall  bladder  is  sometimes  tender  on 
pressure.  Lastly,  on  auscultation  of  the  chest  one  can 
often  hear  dry  or  moist  sounds,  indicating  bronchitis. 

Soon,  however,  the  typical  picture  of  enteric  fever 
begins  to  appear. 

The  headache,  which  is  chiefly  frontal,  gets  more 
severe  during  the  next  few  days.  The  patient  feels 
giddy  when  he  wants  to  raise  his  head  or  sit  up  in  bed. 
He  is  restless  in  his  sleep  and  suffers  from  nightmares. 
The  spleen  increases  in  size  at  the  sixth  or  seventh 
day.  Lastly,  the  temperature  gradually  rises.  It  goes 
up  every  evening  without  returning  in  the  morning  to 
the  point  at  which  it  was  on  the  previous  morning. 
This  is  the  period  of  ascending  oscillations.  The 
pulse  does  not  keep  parallel  with  the  temperature, 
but  is  more  rapid  in  the  evening  than  in  the  morning, 
and  becomes  dicrotic. 

Such  is  the  ordinary  clinical  picture  of  the  first 
period,  which  lasts  from  about  four  to  seven  days. 

Height  of  the  Disease. — In  a  second  period  which 
lasts  on  the  average  from  a  week  to  a  fortnight,  and 
sometimes  more,  the  clinical  picture  becomes  more 
definite.  The  temperature  falls  but  slightly  in  the 
morning  and  keeps  at  about  the  level  of  104°  F.  The 
pulse  becomes  frequent,  soft  and  compressible.  The 
headache  diminishes,  but  the  patient  is  prostrate  and 
his  facies  becomes  characteristic.  During  the  day- 
time he  is  indifferent  to  persons  and  things,  his  in- 
telligence appears  less  on  the  alert,  he  is  slower  in 


6    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

replying  and  he  is  somnolent.  But  as  soon  as  the 
evening  comes  he  begins  to  be  delirious,  gets  restless, 
has  subsultus  tendinum  and  carphology.  After  waking 
up  in  the  morning  he  sinks  back  into  the  state  of  stupor 
{Tvcpog),  which  has  given  its  name  to  the  disease.  At 
the  same  time  the  tongue  becomes  dry  and  brownish 
at  the  base  and  centre,  and  increases  in  length,  and  the 
epithelial  covering  disappears  at  the  tip  and  edges, 
which  assume  a  glazed  and  red  appearance,  intersected 
by  fissures  which  are  sometimes  quite  deep. 

The  lips  are  dry  and  cracked,  and  the  teeth  covered 
with  sordes.  Throughout  this  period  careful  examina- 
tion of  the  abdomen  shows  some  small  isolated  spots, 
circular  in  shape,  with  definite  outline,  pink  in  colour, 
slightly  round  above  the  skin,  disappearing  for  a 
moment  on  pressure,  but  soon  reappearing.  These 
lenticular  pink  spots  are  also  present  in  very  variable 
numbers  on  the  chest  and  sides  of  the  thorax. 

One  may  also  find  ulcers  present  in  the  pharynx, 
the  so-called  Duguet's  ulcers. 

The  skin  is  dry,  but  in  the  morning  it  is  sticky  and 
damp.  Sometimes  it  is  covered  with  "  sudamina." 
The  diarrhoea  becomes  more  foetid,  the  stools  more 
frequent,  the  meteorism  more  pronounced ;  while  the 
pain  caused  by  pressure  on  the  iliac  fossa  is  severe 
enough  to  "  cause  the  face  of  a  comatose  patient  to 
contract  "  (Jaccoud). 

The  spleen  grows  larger  and  often  passes  below  the 
false  ribs. 

The  sphincters  are  sometimes  relaxed,  and  the 
bladder  is  occasionally  sluggish.  The  patient  loses 
flesh  considerably  and  gets  weaker. 

Death  may  occur  in  coma  or  the  patient  may  grad- 
ually become  convalescent. 

Period  of  Defervescence. — The  temperature  falls 
either  suddenly,  which  is  rare,  or  rather  slowly  and 
gradually.  In  the  first  case  "  this  sudden  defervescence 
is  complete  in  twelve  hours,  between  the  evening  of 
one  day  and  the  morning  of  the  next,  or  at  the  latest 
in  thirty -six  hours.     The  dechne  of  the  fever  is  accom- 


CLINICAL    CHARACTERS    OF    TYPHOID    FEVER    7 

panied  by  a  complete  change  in  the  outward  appearance 
of  the  patient  :  his  facies  becomes  bright  and  assumes 
a  normal  expression.  The  organic  recovery  takes 
place  quietly ;  the  phase  of  repair  being  reduced  to  a 
minimum  and  accomplished  uneventfully,  truly  speak- 
ing, forms  a  part  of  convalescence  "  (Jaccoud). 

In  the  second  case,  which  is  much  more  frequent, 
defervescence  takes  place  gradually,  by  lysis.  The 
temperature  drops  at  first  some  tenths  of  a  degree 
each  evening,  and  then,  having  reached  101*8°  or  102*2° 
in  the  evening,  it  falls  to  normal  in  the  morning.  This 
is  the  period  of  descending  oscillations.  The  evening 
temperature  also  gradually  becomes  normal  and 
remains  so. 

While  the  gradual  fall  of  the  temperature  takes 
place  in  this  manner,  the  patient  comes  to  life  again, 
as  it  were.  The  stupor  disappears,  the  delirium  sub- 
sides, the  somnolence  ceases,  and  he  recovers  conscious- 
ness of  his  condition  and  surroundings.  The  tongue, 
gums  and  lips  become  clear,  the  diarrhoea  disappears, 
and  very  often  gives  way  to  constipation  ;  the  meteor- 
ism  diminishes,  more  urine  is  passed,  the  spleen  resumes 
its  normal  dimensions,  sleep  returns,  the  appetite 
revives,  and  improvement  takes  place  daily  until 
recovery  is  complete. 

Such  in  outline  is  the  clinical  picture  of  the  typical 
form,  and  perhaps  the  most  frequent  form,  of  typhoid 
infection.  This  ordinary  form  of  typhoid  fever  has 
special  features  which  may  be  resumed  as  follows — 

1.  Period -of  incubation  of  varying  length,  usually 
two  weeks,  passing  as  a  rule  unnoticed,  or  brought  into 
prominence  by  some  malaise  without  specific  character, 
and  a  very  slight  rise  of  temperature. 

2.  Period  of  invasion  or  onset,  characterised  by  signs 
common  to  every  infection  :  prostration,  dizziness, 
vertigo,  frontal  headache,  pains  in  the  limbs  and  back ; 
coated  tongue,  sticky  mouth,  anorexia,  nausea,  occa- 
sionally vomiting,  thirst,  constipation,  epistaxis,  pain 
in  the  right  iliac  fossa,  swelling  of  the  spleen,  and  a 
special  form  of  temperature  (ascending  oscillations). 


8    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

3.  Height  of  the  disease. — Absolute  anorexia,  caked 
tongue,  dry  lips,  pronounced  meteorism,  gurgling, 
diarrhoea  and  urine  with  special  features,  enlargement 
of  the  spleen,  lenticular  rose  spots,  typhoid  state, 
delirium  usually  of  slight  degree,  stupor,  dicrotic  pulse, 
temperature  at  a  high  level  and  excessive  loss  of  flesh. 

4.  Period  of  defervescence. — Fall  of  temperature, 
sometimes  sudden  (rare),  sometimes  by  lysis  (descend- 
ing oscillations),  polyuria,  return  of  appetite,  and 
disappearance  of  the  various  symptoms. 

But  the  disease  is  far  from  following  step  by  step 
the  schematic  lines  of  this  description,  either  at  its 
onset  or  during  its  course.  Sometimes  one  symptom 
or  group  of  symptoms  dominates  the  scene  ;  sometimes 
the  general  course  of  the  affection  is  prolonged  or  cur- 
tailed ;  and,  lastly,  the  special  features  of  an  attack, 
according  as  it  is  mild  or  severe,  havfe  given  rise  to  the 
description  of  numerous  special  forms. 

From  these  forms  we  will  select  only  those  whose 
retention  appears  specially  justifiable. 

1.  Forms  "with  Special  Onset. — Sudden  onset. — 
Typhoid  fever  has  not  always  a  slow  and  progressive 
onset.  There  are  cases  where  it  "  explodes,"  i.  e. 
begins  suddenly  and  with  great  violence.  Trousseau 
and  Murchison  quote  instances  of  the  kind ;  Vincent 
has  noted  the  special  frequency  of  these  forms  in  Algeria, 
among  malaria  patients. 

The  patients  generally  have  a  violent  headache  and 
a  shivering  attack,  with  a  temperature  about  104°  F. 
In  some  cases  there  are  pains  in  the  joints,  nausea  and 
vomiting. 

The  serum  reaction  is  positive  earlier  than  usual 
(Widal). 

Pneumo-typhoid. — In  exceptional  cases  pneumonia 
may  mark  the  onset  of  typhoid  fever.  The  intensity 
of  the  pulmonary  symptoms  may  cause  one  to  over- 
look the  signs  of  typhoid  fever,  which  is  recognised 
only  at  autopsy.  Pneumonia  and  typhoid  fever  may 
be  concurrent  and  both  be  diagnosed  from  the  first. 
The  pneumonia  subsequently  subsides  and  is  replaced 


CLINICAL   CHARACTERS   OF   TYPHOID   FEVER    9 

by  symptoms  of  typhoid  fever,  which  then  runs  a 
normal  course.  This  pneumo -typhoid  is  regarded  by 
some  authorities  as  the  manifestation  of  the  primary 
locaHsation  of  the  typhoid  bacillus  (Gerhardt,  Lepine, 
Grasset,  Potain) ;  according  to  others  it  is  merely  a 
superadded  disease  (de  Marignac,  Castex).  Laboratory 
investigations  have  not  yet  cleared  up  this  question. 

Numerous  clinical  types  have  been  created  based 
on  the  predominance  of  an  abnormal  symptom,  or  on 
the  more  obvious  localisation  of  the  bacillus  in  a 
special  organ  at  the  onset  of  the  disease. 

Thus  writers  have  described  a  pleuro-typhoid,  in 
which  the  initial  pleurisy  precedes  the  manifestation 
of  the  signs  of  typhoid  fever  by  eight  to  nine  days ; 
arthro-typhoid,  broncho-typhoid,  meningo-typhoid,  etc. 
It  would  certainly  be  easy  to  add  to  these  varieties. 

2.  Forms  in  which  One  or  Several  Symptoms 
Predominate. — Here,  too,  there  has  perhaps  been  a 
needless  multiplication  of  symptomatic  types. 

The  bilious  or  gastric  form,  with  its  bihous  symptoms 
(nausea,  bilious  vomiting,  slight  jaundice)  indicates 
the  invasion  of  the  bile  ducts  by  the  typhoid  bacillus. 
It  is  frequent  in  hot  climates,  and  has  often  been 
observed  in  the  course  of  the  present  war. 

Hcemorrhagic  form. — All  the  principal  infections  may 
assume  the  ha^morrhagic  form.  Typhoid  fever  is  no 
exception  to  this  rule.  In  addition  to  the  initial 
epistaxis,  the  mechanism  of  which  is  unexplained,  and 
the  hsemorrhage  from  the  gums  or  mouth  due  to  ulcera- 
tion of  the  gums  or  mucous  membrane,  haemorrhagio 
nephritis,  due  to  typhoid  infection,  is  also  found. 
Lastly,  intestinal  haemorrhage,  which  is  more  common, 
has  a  special  pathogeny  with  which  we  shall  deal 
later. 

These  haemorrhagic  forms  may  have  an  epidemic 
character  (Leudet),  which  is  perhaps  explained  by  the 
activity  of  the  toxins  secreted  by  some  strains  of  the 
typhoid  bacillus. 

These  haemorrhages  may  occur  at  any  period  of  the 
disease,  in  any  organ  and  in  all  parts  of  the  body  : 


10    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

e.  g.  skin,  mucous  and  serous  membranes,  intestine, 
uterus,  lung,  meninges,  pleurse,  muscles,  etc.  The 
temperature  is  high,  the  heart  fails  and  the  patient  is 
unable  to  offer  any  resistance.  Death  is  very  frequently 
the  termination  of  these  cases. 

3.  Forms  with  a  Shortened  or  Prolonged 
Course. — Abortive  typhoid  fever  {typhus  levissimus). 
— Under  this  denomination  are  included  "typhoid 
febricula  of  short  duration,  attenuated  typhoid  and 
certain  cases  of  typhoid  fever  which  are  severe,  but 
end  in  rapid  recovery  before  the  ordinary  period  of 
convalescence  "  (Letulle).  They  are  fairly  often  seen 
in  incompletely  vaccinated  subjects. 

This  abortive  form  of  typhoid  fever  is  specially 
found  in  children  and  is  more  frequent  in  certain 
epidemics  (Letulle).  At  the  onset  the  tempera.ture 
may  be  very  high,  rising  on  the  evening  of  the  fourth 
or  fifth  day  to  104°  or  104-6°  F.,  and  associated  with 
headache  and  complete  insomnia ;  vomiting  is  not 
uncommon,  the  patient  is  usually  constipated,  there 
may  be  epistaxis.  The  rose  spots  appear  from  the 
seventh  to  the  tenth  day,  but  may  be  absent  (Letulle). 

The  spleen  is  usually  enlarged.  The  pulse  is  not 
very  rapid,  70  to  90.  The  other  symptoms  are  those 
of  ordinary  typhoid  fever.  The  temperature  may 
decline  gradually  to  normal,  or  fall  suddenly  with 
copious  perspiration.  Critical  polyuria  may  occur. 
These  abortive  fevers  are  frequently  followed  by 
relapses  which  are  themselves  often  slight  and  abortive, 
but  may  be  severe  and  fatal. 

Prolonged  typhoid  fever. — In  very  exceptional  cases 
typhoid  fever  is  prolonged  far  beyond  the  ordinary 
limits.  In  one  of  Murchison's  cases  the  appearance 
of  rose  spots  was  noted  almost  daily  from  the  fourteenth 
to  the  sixtieth  day.  Typhoid  fevers  have  been  re- 
corded which  have  lasted  seventy  and  ninety  days. 
In  the  so-called  recrudescing  forms  the  temperature 
shows  a  very  slight  fall,  but  soon  returns  to  its  former 
level,  so  that  the  duration  of  the  disease  may  be  thus 
considerably  prolonged.     In  other  cases  the  period  of 


CLINICAL  CHARACTERS  OF   TYPHOID  FEVER    11 

defervescence  is  very  long,  but  as  a  rule  it  is  an  excep- 
tionally protracted  amphibolic  stage  which  prolongs 
the  febrile  period. 

4.  Mild  and  Severe  Forms. — Typhoid  fever  pre- 
sents all  the  intermediate  degrees  between  apyrexia 
and  hyperpyrexia ;  the  temperature  being  as  a  rule 
the  faithful  expression  of  the  severity  of  the  disease. 

Insidious  or  latent  form. — Ambulatory  form. — This 
form  has  been  carefully  studied  by  Louis,  and  Chomel 
and  Louis.  The  expression,  "  ambulatory  form," 
designates  its  special  feature ;  the  patient  is  up  and 
about,  and  continues  his  ordinary  occupation.  In 
this  form  the  symptoms  are  generally  mild.  The 
patient  may  have  irregular  shivers,  alternating  with 
flushes  and  feelings  of  heat,  slight  headache  and 
lassitude ;  the  appetite  is  lost,  and  sleep  disturbed. 
There  may  be  diarrhoea  or  constipation.  The  pulse 
is  sometimes  a  little  quickened,  but  may  remain 
normal ;  rose  spots  may  be  found,  as  well  as  enlarge- 
ment of  the  spleen.  Fever  may  either  be  absent  or 
very  high  (Jaccoud).  Sometimes  the  ambulatory  fever 
retains  its  character  throughout  and  ends  in  recovery 
without  the  patient  taking  to  bed.  Sometimes  towards 
the  twelfth  or  fifteenth  day  the  typical  assemblage  of 
typhoid  symptoms  appears.  Lastly,  in  some  cases 
the  condition  suddenly  becomes  alarming.  The  patient 
develops  acute  delirium  or  a  sudden  intestinal  hasmor- 
rhage,  which  may  end  fatally ;  or,  more  commonly, 
symptoms  of  perforation  appear,  with  acute  peritonitis, 
which  is  fatal  in  a  few  hours.  Sometimes  sudden 
death  terminates  what  seemed  to  be  quite  a  mild 
infection.  The  patient  succumbs  to  myocarditis  with 
stoppage  of  the  heart.  This  cause  of  death  has  often 
been  observed  during  the  present  war. 

Febrile  gastric  derangement,  synoclius  or  typhoid 
febricula,  belongs  to  the  same  clinical  category  as 
typhus  levissimus. 

This  variety  lasts  seven  to  twelve  days  at  most, 
and  then  the  patient  is  quite  well  again.  This  febrile 
gastric    derangement,    which    may    also    indicate    a 


12    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

paratyphoid  infection,  does  not  always  run  a  mild 
course. 

A  blood-culture  may  confirm  the  diagnosis,  as  in 
certain  so-called  apyretic  cases,  in  which  the  patient  has 
no  fever  and  complains  only  of  vague  discomfort 
and  shows  signs  of  anaemia  and  progressive  weakness. 
This  last  form  may  be  seen  in  enfeebled  persons  and 
subjects  of  chronic  malaria. 

Ataxo-adynamic  or  hyperpyretic  form. — The  old 
physicians  used  to  differentiate  between  an  ataxic  form 
and  an  adynamic  form. 

In  reality  these  two  symptoms  are  as  a  rule  associated, 
and  are  both  accompanied  by  a  high  and  prolonged 
temperature. 

The  ataxia  is  shown  by  more  or  less  violent  nervous 
disturbance :  delirium,  convulsions,  subsultus,  car- 
phology,  etc.,  alternating  with  adynamia,  i.  e.  prostra- 
tion, stupor  and  weakness  of  the  voice.  At  the  same 
time,  feebleness  of  the  pulse  corresponding  to  the 
myocardial  lesions  becomes  evident.  The  patient  has 
frequent  fluid  stools,  which  are  sometimes  involuntary, 
and  bedsores.  The  temperature  ranges  between  104-8° 
and  106*6°  F.,  with  very  sUght  oscillations  between  the 
evening  and  morning  records. 

The  ataxo-adynamic  form  with  hyperpyrexia  is 
extremely  grave.  Fulminating  cases  may  occur  which 
commence  suddenly  with  violent  headache  and  delirium, 
and  terminate  fatally  in  a  few  days. 

Typhoid  fever  may  assume  special  characters 
according  to  the  state  of  the  individual  whom  it 
attacks.  The  age,  previous  health,  and  co -existence 
of  another  infection  profoundly  modify  the  clinical 
characters  of  the  disease.  We  will  now  study  each  of 
these  modifications  in  turn. 

Typhoid  Fever  according  to  Age 

Typhoid  Fever  in  Children.  —  (a)   Infancy. — 

Typhoid  fever  in  the  infant  is  rather  rare.  At  this 
age  the  diagnosis  is  peculiarly  difficult.     According  to 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    13 

Comby  and  Marfan,  typhoid  fever  is  exceptional  in 
the  first  six  months  of  Ufe ;  from  six  months  to  two 
years  its  frequency  increases. 

Hutinel  and  Darre  state  that  the  principal  cause  of 
this  immunity  is  the  fact  that  the  child  does  not  leave 
the  arms  of  its  mother  or  nurse,  and  consequently  is 
but  little  exposed  to  direct  contagion.  Its  mode  of 
feeding  may  also  explain  this  rarity  of  infection. 
When  typhoid  fever  does  occur  at  this  age,  it  is  severe 
owing  to  pulmonary  compHcations,  especially  secondary 
broncho -pneumonia  of  streptococcal  nature,  which  is 
fairly  often  superimposed  on  the  typhoid  process. 

In  the  case  of  a  feverish  infant  one  should  first  of 
all  think  of  the  eruptive  fevers,  and  then  of  sore  throat. 
The  appearance  and  number  of  the  stools,  which  are 
usually  very  liquid,  foetid,  yellowish,  sometimes  greenish 
in  colour,  of  porridgy  consistence,  and  twelve  to  twenty- 
five  a  day ;  the  acceleration  of  the  pulse,  without 
dicrotism ;  the  appearance  of  rose  spots  combined  with 
enlargement  of  the  spleen ;  the  state  of  prostration 
or,  on  the  other  hand,  the  infant's  incessant  cries 
and  restlessness,  are  symptoms  which  should  sug- 
gest typhoid  fever.  The  serum  reaction  should  be 
investigated. 

Typhoid  fever  in  the  infant  may  assume  one  of  three 
forms. 

In  the  gastro-intestinal  form  the  prostration  is 
considerable  ;  the  little  patient  vomits  its  feeds  and 
loses  flesh  considerably.  The  stools  are  numerous 
(six,  twelve  or  twenty-five  in  the  twenty-four  hours), 
sometimes  glairy  (Nobecourt  and  Voisin).  Green 
diarrhoea  is  fairly  frequent  and  is  accompanied  by  a 
high  temperature.  "  This  form  is  terribly  fatal," 
says  Marfan,  "  and  as  a  rule  in  a  few  days'  time  a 
choleriform  enteritis  develops,  probably  due  to  a 
secondary  infection,  which  carries  off  the  patient." 

In  the  meningeal  form  the  chnical  picture  recalls 
that  of  meningitis  :  cries,  restlessness,  vomiting,  very 
rapid  pulse,  fever  without  remission,  constipation,  a 
wild    look,    and    strabismus.     These    phenomena    of 


14    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

excitement  are  succeeded  by  pronounced  prostration. 
Trousseau's  meningeal  streak  appears.  Lumbar 
puncture  gives  issue  to  a  fluid  under  tension,  and 
causes  a  decided  improvement  in  the  little  patient's 
condition.  In  other  cases  the  reaction  is  intense ; 
colic,  shivering,  vomiting,  inequality  of  the  pupils, 
ptosis,  very  pronounced  internal  strabismus,  Cheyne- 
Stokes  respiration,  and  death  within  ten  days. 

The  least  unfavourable  variety  is  the  so-called 
febrile  form. 

"A  little  diarrhoea,  prostration,  slight  nervous 
phenomena,  but  nothing  striking  :  the  fever  is  the 
chief  symptom  "  (Hutinel  and  Darre).  The  tempera- 
ture curve  sometimes  resembles  that  of  an  adult,  but 
as  a  rule  it  is  rather  irregular. 

In  favourable  cases  the  fall  of  the  temperature  takes 
place  slowly  by  lysis,  occupying  a  whole  week. 

{h)  Childhood. — Typhoid  fever  is  fairly  frequent 
in  the  child  about  seven  or  eight  years  of  age,  but  is 
less  severe  than  in  the  adult.  The  duration  is  also  less, 
a  fortnight  only  on  the  average,  instead  of  a  minimum 
of  three  weeks. 

Abortive  or  curtailed  forms  are  frequent. 

The  onset  is  often  sudden,  accompanied  by  vomit- 
ing lasting  for  twenty-four  or  forty-eight  hours,  or 
appendicular  symptoms,  or  torticollis  resembling 
rheumatic  wry -neck.  It  may  also  simulate  meningitis. 
In  these  cases  the  temT.erature  goes  up  at  once  to  about 
104°  F.  These  high  temperatures  of  104°  and  above 
have  not  the  same  severe  prognosis  as  in  the  adult. 

The  pulse  is  relatively  slow,  90  to  100  or  110  (Hutinel). 
According  to  Thoinot  and  Ribierre  it  is  more  rapid 
than  in  the  adult  (150-180  in  very  young  children; 
100-140  in  older  children). 

Persistent  constipation  is  almost  the  rule,  followed 
by  diarrhoea  at  a  late  stage.  Meteorism  is  often  ill- 
marked.  In  some  exceptional  cases,  however,  the  belly 
is  much  distended,  diarrhoea  develops  and  becomes 
profuse.     Enlargement  of  the  spleen  is  almost  constant. 

Rose  spots  are  more  frequently  absent  in  the  child 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    15 

than  in  the  adult.  They  usually  appear  from  the  sixth 
to  the  twelfth  day.  They  are  sometimes  particularly 
abundant  and  may  become  generalised  (exanthematic 
form).  The  heart  sounds  may  assume  the  embryo - 
cardiac  rhythm,  the  extremities  becoming  cyanosed. 
Arteritis  is  infrequent ;  .phlebitis  occurs  fairly  often. 
Haemorrhages,  though  not  harmless,  are  rarely  fatal. 
Perforation  occurs  only  in  children  of  a  certain  age. 
It  is  manifested  by  a  fall  of  temperature,  abdominal 
distension,  and  later  by  porraceous  vomiting.  Colitis 
may  mask  the  onset  or  occur  in  the  course  of  typhoid 
fever.  "  In  that  case  it  is  most  frequently  produced 
by  enemata  of  boiled  water  which  are  not  isotonic, 
and  cause  the  passage  of  mucus  and  membrane  into  the 
stools.  To  make  matters  right  again,  enemata  of 
mucilage  are  all  that  is  required  "  (Hutinel). 

In  the  course  of  typhoid  fever  in  the  child  we  may 
meet  with  meningeal  reactions  (meningism  of  Dupre), 
suppurative  meningitis,  pyelitis,  and  pyelonephritis ; 
the  last  two  complications  supervening  when  the  child 
has  previously  had  a  renal  affection. 

Albuminuria  is  frequent. 

Aphasia  of  transient  duration  and  without  verbal 
deafness  has  been  recorded. 

Periostitis,  especially  of  the  tibia,  is  not  rare. 
Otorrhoea  is  fairly  frequent,  causing  deafness  and  often 
deaf-mutism  in  young  children,  who  'forget  how  to 
talk. 

Besides  desquamation  and  loss  of  hair,  one  may 
observe  erythemata  in  young  children,  which  indicate 
a  severe  infection.  Such  cases  present  ulceration  and 
fissures  of  the  lips,  ulceration  of  the  pharynx,  and 
streptococcal  ulceration  of  the  skin.  The  patient  is 
cyanosed,  his  temperature  shows  a  sudden  drop,  the 
arterial  pressure  is  low,  the  abdomen  retracte'd,  and  he 
lies  in  a  state  of  profound  depression  (Hutinel,  Loiseau). 

These  are  the  grave  forms  which  sometimes  assume 
an  epidemic  character. 

Generally  speaking,  with  the  exception  of  infants, 
typhoid   fever  in   the    child    has   a   more   favourable 


16    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

prognosis  than  in  the  adult,  and  is  especially  favourable 
at  about  the  age  of  ten  or  twelve  years. 

Typhoid  in  the  Aged. — Although  typhoid  fever  is 
rare  above  40,  fairly  numerous  examples  are  to  be  met 
with  (61,  70,  73,  86,  90  and  100  in  a  case  of  Gueneau 
de  Mussy).  Its  course  is  then  abnormal  and  the 
prognosis  extremely  grave,  doubtless  on  account  of  the 
visceral  lesions  of  the  heart,  kidneys,  lungs  and  arteries, 
which  so  frequently  accompany  old  age.  "  The  onset 
is  usually  insidious ;  debility  and  tremors  are  often 
prominent  symptoms ;  the  type  of  the  fever  is  essen- 
tially adynamic.  Rose  spots,  acute  delirium  and  urgent 
diarrhoea  are  rarely  observed.  The  pyrexia  is  usually 
protracted,  but  the  temperature,  even  in  fatal  cases, 
is  rarely  so  high  as  in  younger  persons,  and  more  often 
falls  below  normal  "  (Murchison).  We  may  add  that 
pulmonary  phenomena  play  an  important  part  and 
are  frequently  responsible  for  the  fatal  termination. 

Convalescence  is  always  protracted,  owing  to  gastro- 
intestinal troubles  and  mental  disturbances,  such  as 
loss  of  memory,  which  is  often  permanent,  or  cardiac 
disorder  which  fairly  frequently  terminates  by  collapse. 

Typhoid  Fever  in  Pregnancy. — Pregnancy  in 
itself  is  not  an  aggravating  factor  in  typhoid  fever. 
But  the  disease  may,  by  its  effect  on  the  foetus,  cause 
abortion  or  premature  delivery  in  about  one  out  of 
three  cases.  Advanced  pregnancy  particularly  pre- 
disposes to  abortion,  which  may  occur  at  any  period 
of  the  disease,  from  the  first  week  till  the  first  days  of 
convalescence  (Hutinel). 

In  the  great  majority  of  cases  the  foetus  is  expelled 
dead;  when  the  child  is  ahve  its  blood  presents 
agglutinating  properties  (Widal  and  Sicard).  Death 
of  the  foetus  has  been  attributed  to  profuse  haemorrhage 
from  the  endometrium  or  to  hyperthermia,  although 
this  suggestion  has  not  been  confirmed. 

The  presence  of  specific  agglutinins  or  of  the  actual 
typhoid  bacillus  in  the  blood  (Chantemesse  and  Widal, 
Legry,  6tienne,  Marfan,  etc.)  or  organs  of  the  expelled 
foetus,  suggests  that  the  foetus  may  succumb  to  the 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    17 

direct  action  of  the  infection  transmitted  to  it  by  the 
mother. 

Typhoid  Fever  in  the  Course  of  Various 
Pathological  Conditions. — Certain  persons  who  are 
already  suffering  from  an  acute  or  chronic  disease 
may  contract  typhoid  fever,, or  an  acute  infection  may 
be  grafted  upon  an  already  existing  typhoid  fever. 
This  combination  gives  rise  to  the  following  interesting 
clinical  forms. 

Typhoid  fever  and  acute  exanthemata. — Murchison 
has  recorded  a  case  in  which  typhoid  fever  was  com- 
plicated by  variola  and  vaccinia.  Barthez  and  Rilhet, 
Taupin,  Jenner  and  Kesteven  have  seen  cases  of 
co-existent  typhoid  fever  and  measles. 

Scarlatina  has  often  been  noted  in  typhoid  fever. 
Usually  the  patient  suffering  from  typhoid  fever  is 
admitted  to  hospital,  where  he  contracts  scarlatina. 
In  a  certain  number  of  hospitals,  both  for  children 
and  adults,  all  diseases  are  treated  in  the  same  ward. 

Typhoid  fever  and  diphtheria. — In  children's  hospitals 
an  attack  of  faucial  diphtheria  in  typhoid  fever  may 
prove  fatal  in  forty -eight  hours.  The  association  of 
diphtheria  and  typhoid  fever  often  has  a  grave  prog- 
nosis in  the  adult  also. 

E.  Rathery  has  recorded  an  epidemic  of  typho- 
diphtheria  in  the  army,  in  which  the  asthenic  cardio- 
bulbar  forms  were  remarkably  frequent.  Side  by  side 
with  these  forms  there  were  others,  dyspnoeic  forms 
of  an  asphyxial  type,  as  well  as  larjmgeal,  broncho- 
pulmonary and  nervous  forms  of  a  meningeal  type. 
Rathery  regards  the  peculiar  dry  state  of  the  mouth  in 
typhoid  patients  as  likely  to  exalt  the  virulence  of  the 
diphtheria  bacillus  in  the  highest  degree.  Marcel 
Labbe,  who  saw  nine  cases  in  a  month,  states  that  the 
association  of  typhoid  and  diphtheria  is  shown  by  an 
aggravation  of  the  general  symptoms,  a  persistently 
high  temperature,  weakness  of  the  heart,  a  small  and 
feeble  pulse,  diminution  of  the  urine  and  coldness  of 
the  extremities. 

Typhoid    fever    and    tuberculosis. — A      tuberculous 


18    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

patient  may  contract  typhoid  fever  which  develops 
normally,  but  in  convalescence  the  tuberculosis  may 
take  on  a  rapid  course.  It  is  not  exceptional  to  see  a 
convalescent  from  typhoid  develop  undoubted  signs 
of  tuberculosis,  and  even  of  acute  phthisis. 

Erysipelas  is  a  grave  complication  of  typhoid  fever, 
but  has  become  rare  since  more  care  has  been  given 
to  the  lesions  of  the  skin  which  are  so  frequent  in  typhoid 
patients. 

The  occurrence  of  streptococcal  infection,  at  the 
onset  or  in  the  course  of  typhoid  fever,  has  formed  the 
object  of  a  special  study  (H.  Vincent),  owing  to  the 
gravity  of  its  prognosis. 

When  the  streptococcal  infection  occurs  in  the  first 
stage  of  typhoid  fever,  it  may  be  the  cause  of  disease 
without  any  affection  of  Peyer's  patches.  The  patient 
succumbs  to  a  veritable  strepto-typhoicl  septiccemia, 
his  blood  containing  an  abundance  of  both  micro- 
organisms. When  it  appears  in  the  course  of  typhoid 
fever,  it  is  much  less  severe. 

Pneumonia  may  occur  during  typhoid  fever ;  the 
pneumococcus  is  present  in  the  sputum.  It  may  be 
carried  to  the  meninges  and  determine  an  extremely 
acute  meningitis,  or  an  exudative  meningitis  with  a 
pseudo -membranous  investment  in  which  the  pneurno- 
coccus  will  also  be  found. 

The  bacillus  pyocyaneus  and  proteus  vulgaris  may, 
by  secondary  infection,  invade  the  blood  or  viscera  of 
the  typhoid  patient,  but  these  complications  are  very 
rare  (H.  Vincent), 

Cases  of  cholera  (Girode)  and  tetanus  (Rouget)  in 
typhoid  fever  have  been  recorded. 

In  alcoholic  patients  typhoid  fever  assumes  a  severe 
character.  At  the  onset  the  symptoms  are  those  of 
an  ataxo -adynamic  fever  without  the  hyperthermia 
being  excessive.  The  principal  symptoms  are  delirium, 
cardiac  paresis  and  ataxia.  Haemorrhages  and  bed- 
sores are  frequent. 

In  diabetic  patients  typhoid  fever  often  runs  its 
course  without  causing  much  disturbance ;    the  tem- 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    19 

perature  is  little  raised,  and  the  disease  may  be  mild 
and  almost  latent.  The  glycosuria  persists,  and  the 
diabetes  is  in  no  way  modified  in  its  character  or 
evolution. 

Typhoid  fever  is  a  serious  complication  in  cardiac 


Fig.  1. — Typho -malarial  fever.  Unusual  acceleration  of  pulse 
(140-162)  after  25th  day,  myocarditis  with  embryocardia  and 
death. 

and  'pulmonary  diseases,  the  pre-existing  lesions  being 
aggravated  by  the  new  infection. 

Influenza  fairly  frequently  precedes  typhoid  fever. 
Potain  has  dra^vn  attention  to  the  mild  character  of 
this  post-infiuenzal  fever,  whereas  Siredey,  on  the 
other  hand,  has  seen  severe  and  fatal  cases  under  the 
same  conditions. 

Lastly,    Kelsch    and     Kiener    and    Vincent    have 


20    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

described,  under  the  name  of  typho -malaria,  the 
association  of  malaria  and  typhoid  fever  in  the  same 
individual.     (Fig.  1). 

In  malarial  patients  the  onset  of  typhoid  fever  is 
often  sudden,  being  characterised  by  a  frank  attack 
in  the  form  of  a  quotidian  fever  with  shivering.  But  the 
fever  very  rapidly  becomes  continuous.  The  ordinary 
severe  typhoid  symptoms  then  develop,  especially 
if  the  malaria  is  not  treated,'  viz.  profuse  diarrhoea, 
lenticular  rose  spots,  meteorism,  enlargement  of  the 
spleen  and  adynamic  nervous  troubles ;  while  the 
malaria  is  revealed  by  enlargement  of  the  liver,  the 
earthy  complexion  and  the  periodic  or  irregular 
temperature.  Sometimes  pernicious  attacks  occur 
during  convalescence  and  prove  fatal. 

As  regards  skin  affections  (eczema,  scabies,  hard 
chancres,  etc.)  they  are  only  temporarily  modified  by 
the  typhoid  process. 

Termination  of  Typhoid  Fever 

Death  may  occur  at  various  periods  of  the  disease, 
but  rarely  before  the  fourteenth  day. 

In  hot  countries,  and  also  in  overwrought  soldiers, 
in  war  time,  it  is  not  exceptional  to  meet  with  death 
on  the  eighth  and  even  on  the  sixth  day  of  the  disease, 
death  being  due  to  the  hypertoxic  forms. 

Death  may  be  the  consequence  of  the  severity  of  the 
infection ;  of  localised  complications,  such  as  peri- 
tonitis, intestinal  perforation,  rupture  of  the  gall- 
bladder, intestinal  haemorrhage,  myocarditis,  nephritis, 
etc. ;  of  superadded  infections,  such  as  streptococcal 
or  staphylococcal  septicaemia,  pneumonia,  broncho- 
pneumonia, diphtheria,  etc. 

It  may  occur  suddenly  without  a  cry,  a  movement 
or  a  complaint  of  any  kind.  This  sudden  death,  which 
is  not  uncommon  (1  to  3  per  cent,  of  the  cases)  most 
frequently  takes  place  in  the  third  week.  It  has 
been  attributed  to  various  causes,  e.  g.  an  intestinal 
reflex   (Dieulafoy),   degeneration  of  the   myocardium 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    21 

(Hayem),  cardiac  thrombosis  (Marvaud),  cerebral 
anaemia  (Huchard,  Laveran),  pulmonary  embolism, 
neuritis  of  the  cardiac  plexus,  profuse  intestinal 
haemorrhage,  etc.  Myocarditis  seems  to  have  been 
one  of  the  most  frequent  caus.es  of  rapid  or  sudden 
death  in  the  present  war.  During  the  Tunis  expedi- 
tion one  typhoid  patient  out  of  six  succumbed  suddenly 
(Czernicki). 

The  percentage  mortality  varies  and  is  subordinate 
to  the  age,  sex,  nature  of  the  treatment,  degree  of 
gravity  of  certain  epidemics,  climate  and  previous 
condition  of  fatigue  or  overwork. 

In  childhood  the  mortality  is  only  3  to  5  per  cent., 
sometimes  it  is  lower  still.  In  the  adult  the  average  is 
11  to  14  per  cent. 

In  the  aged  the  course  of  the  disease  is  more  rapid, 
and  death  is  very  common.  The  mortality  in  women 
is  lower  than  in  men. 

The  rational  employment  of  cold  baths  has  appre- 
ciably diminished  the  gravity  of  the  infection,  and 
the  number  of  deaths.  Some  epidemics,  however,  are 
remarkable  for  a  high  mortality,  and  others  for  their 
milder  character,  which  indicates  the  varying  patho- 
genic power  of  the  different  strains  of  the  typhoid 
bacillus,  as  is  the  case  with  the  bacilli  of  dysentery, 
cholera,  etc.  In  hot  countries  the  case  mortality  is 
considerably  higher  than  in  cold  or  temperate  climates, 
either  because  the  external  temperature  adds  its  own 
influence  to  that  of  the  fever,  or  because  the  micro- 
organisms are  more  toxic. 

Lastly,  in  patients  in  broken-down  health,  or  who 
have  come  under  treatment  late,  or  who  have  been 
overworked,  the  mortality  may  be  as  high  as  20  and 
even  25  per  cent.  The  state  of  war  greatly  predisposfes 
to  a  grave  prognosis  in  combatant  soldiers,  among 
whom  the  mortality  is  very  high. 

Recovery  only  takes  place  after  a  more  or  less  pro- 
tracted period  of  convalescence,  which  may  be  normal  or 
complicated. 

"  Convalescence  can  only  be  said  to  be  fairly  estab- 


22    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

lished  when  the  temperature  is  normal  on  two  successive 
evenings  "  (Murchison).  But  it  is  still  very  unstable. 
By  the  time  convalescence  begins  the  patient  has 
become  very  thin,  the  loss  of  weight  sometimes  amount- 
ing in  the  course  of  the  disease  to  200-300  grammes 
per  day,  and  even  more.  His  skin  is  of  a  peculiar 
colour  :  "he  has  the  face  of  a  starved  man  "  (Hutinel). 
His  cheeks,  hitherto  coloured  by  fever,  become  de- 
cidedly pale.  His  pulse  is  irregular,  is  quickened  by 
the  slightest  effort,  an  insignificant  emotion,  or  the 
doctor's  visit.  The  appetite  returns,  however,  and  is 
truly  ravenous.  The  urine,  after  the  transient  polyuria 
and  chloride  discharge,  becomes  normal  again  in 
quantity,  and  poor  in  chlorides  and  urea.  The  mus- 
cular system  is  weakened,  walking  and  standing  are 
difficult  and  painful,  the  patient  is  quickly  tired  but 
recovers  his  strength  gradually.  The  skin  peels,  the 
nails  present  furrows  and  depressions,  the  hair  falls 
out  but  grows  again  as  repair  takes  place,  the  weight 
increases  and  the  ansemia  disappears. 

Some  convalescents  will  be  found  to  have  lost  their 
memory  and  present  disturbances  of  hearing,  taste 
and  smell ;  they  are  very  impressionable,  and  some- 
times show  temporary  modifications  in  their  character 
(excessive  apathy,  starvation  delirium  or  irritability). 
As  a  rule,  however,  the  disappearance  of  fever  is 
accompanied  by  a  marked  sense  of  well-being. 

The  duration  of  convalescence  varies  considerably, 
being  more  rapid  in  children  and  longer  in  adults  above 
forty  years  of  age. 

There  are  few  cases  of  typhoid  fever  in  which  the 
disease  or  convalescence  is  not  interrupted  either  by 
some  slight  incident  or  grave  complication. 

Typhoid  fever  is  pre-eminently  a  disease  with 
complications. 

Venous  thrombosis  is  a  fairly  common  occurrence 
in  convalescence,  being  due  to  the  growth  of  the 
staphylococcus,  and  in  exceptional  cases  of  the  strep- 
tococcus, in  which  case  the  prognosis  is  very  grave. 
Typhoid  arteritis  is  rarer.     Convalescents  sometimes 


CLINICAL  CHARACTERS  OF  TYPHOID  FEVER    23 

suffer  from  obstinate  vomiting,  which  may  become 
uncontrollable  and  even  be  the  cause  of  death. 

Cachectic  diarrhoea  may  persist  indefinitely  and 
considerably  weaken  the  patient.  Paralysis  from 
neuritis,  abscesses  and  boils  are  not  rare.  Some 
convalescents  may  show  oedema  without  albuminuria, 
which  clears  up  in  two  or  three  weeks,  and  the  patho- 
geny of  which  is  still  obscure.  After  long  and  severe 
illnesses  bedsores  may  be  the  starting-point  of  septi- 
caemia, which  is  sometimes  fatal.  The  temperature 
ought  to  be  normal  in  convalescence,  but  the  ther- 
mometer may  rise  for  some  hours  under  the  influence 
of  fatigue,  emotion,  excess  of  food  or  a  meat  diet 
(febris  carnis). 

When  the  rise  of  temperature  lasts  for  more  than  a 
day  it  becomes  the  first  symptom  either  of  an  inter- 
current complication  (phlegmasia  alba  dolens,  osteitis, 
various  suppurative  lesions,  etc.)  or  of  the  interruption 
of  convalescence  by  a  relapse. 

Relapses 

By  a  relapse  of  typhoid  fever  should  be  understood 
a  second  evolution  of  the  specific  febrile  process  after 
convalescence  from  the  first  attack  is  fairly  established. 
Relapses  should  not  be  confounded  with  recrudescences, 
which  are  common  during  the  period  of  ulceration, 
nor  with  second  attacks. 

Recrudescences  are  aggravations  of  the  typhoid 
symptoms  which  usually  occur  in  the  period  of  deferves- 
cence. The  disease  "  rebounds,"  so  to  speak,  and  when 
it  appears  to  be  on  the  way  to  convalescence,  it  breaks 
out  again. 

A  relapse  is  a  revival  of  typhoid  fever  in  actual 
convalescence  ;  that  is  to  say,  when  the  patient  has 
had  a  normal  temperature  for  several  days. 

The  second  attack  is  a  fresh  attack  of  typhoid  fever 
occurring  a  very  long  time  after  recovery  from  the 
first.  Although  as  a  rule  the  first  attack  confers  im- 
munity,  this   immunity   may   be   attenuated   or  lost 


24    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

after  a  varying  period  of  time,  thus  rendering  possible 
a  fresh  typhoid  infection. 

The  relapse  begins  from  eight  to  thirty  days  after 
the  termination  of  the  febrile  cycle  (Jaccoud) ;  as  a 
rule,  however,  it  does  not  develop  after  the  end  of  the 
first  fortnight.  It  may  start  after  an  apyrexial  period 
of  from  one  to  three  days. 

It  reproduces  completely  and  in  their  normal  order 
all  the  symptoms  of  typhoid  fever. 

The  first  symptom  is  the  rise  of  temperature,  which 
may  occur  just  as  at  the  onset  of  typhoid  fever,  viz. 
either  suddenly  or  by  more  or  less  pronounced  ascending 
oscillations,  with  or  without  shivering.  The  ordinary 
symptoms  reappear.  The  eruption  of  rose  spots 
appears  earlier  than  in  the  first  attack. 

The  duration  of  the  second  attack  is  usually,  but  not 
invariably,  shorter  than  that  of  the  first.  As  a  rule, 
the  relapse  is  fairly  mild.  The  severity  of  the  relapse 
has  no  relation  to  that  of  the  initial  disease.  In  a 
third  or  quarter  of  the  cases  the  symptoms  are  severer 
than  in  the  first  attack.  The  relapse  is  not  always 
single.  Cases  of  typhoid  fever  with  multiple  relapses 
have  been  seen,  e.  g.  two  (Trousseau,  Stewart,  Mac- 
lagan),  three  (Bucquoy,  Jaccoud,  etc.),  four  (Hallo- 
peau),  and  even  five  relapses  (Jaccoud).  Perhaps  the 
last  was  a  case  of  Malta  fever. 

Sequelae  of  Typhoid  Fever 

In  the  majority  of  cases  recovery  from  typhoid  fever 
takes  place  without  any  sequelse. 

Typhoid  fever  may,  however,  leave  behind  lasting 
traces  of  its  visit  in  the  form  of  disablement  and  chronic 
visceral  lesions,  or  pathological  states  which  appear 
during  the  fever  and  continue  their  course  after  the 
fever  has  ended. 

Writers  have  recorded  cases  of  prolonged  and  even 
permanent  enfeeblement  of  the  memory,  slowness  of 
perception,  difficulty  in  the  formation  of  ideas,  dis- 
turbance of  speech,  and  in  children  and  young  persons 


CLINICAL  CHARACTERS  OF   TYPHOID  FEVER    25 

"  a  lowering  of  the  intelligence,  which  increases  through 
want  of  exercise,  and  may  end  in  a  condition  bordering 
on  imbecility  "  (Jaccoud). 

Acute  mania,  melancholia,  megalomania,  religious 
mania,  etc.,  have  been  observed  as  the  results  of  typhoid 
fever. 

Polyneuritis,  disseminated  sclerosis,  chorea  and 
anterior  pohomyelitis  have  been  recorded. 

Nephritis  is  rather  rare  ;  paratyphoid  appendicitis 
has  been  described  by  Dieulafoy. 

Prolonged  infections  of  the  bile  ducts,  and  some 
forms  of  biliary  cirrhosis  may  be  attributed  to  a  previous 
typhoid  infection,  owing  to  growth  of  the  bacillus  in 
the  gall-bladder  and  bile  ducts. 

There  are  many  cases  on  record  of  osseous  and 
articular  lesions  ^  such  as  hip- joint  disease  and  coxo- 
femoral  dislocation,  as  well  as  mutilations  of  the 
extremities  following  gangrene  due  to  arterial  oblitera- 
tion. Lastly,  in  the  antecedents  of  patients  suffering 
from  leukeemia,  Hodgkin's  disease  (Reynaud),  and 
splenic  pseudo -leukaemia,  typhoid  fever  has  been  noted, 
without,  however,  any  demonstration  of  the  relation  of 
cause  and  effect  between  these  diseases  and  the  typhoid 
infection. 


CHAPTER    II 

CLINICAL   CHARACTERS    OF   TYPHOID    FEVER 

[continued). 

Analysis   of   Symptoms   and   Complications 
according  to  their  Anatomical  Situation 

Digestive  System 

The  symptoms  presented  by  the  digestive  organs 
in  typhoid  fever  are  most  important.  Except  in  the 
mild  cases,  where  the  patient  preserves  it  throughout 
the  disease,  the  appetite  is  already  declining  in  the 
incubation  period  and  is  completely  lost  at  the  height 
of  the  disease,  to  reappear  again  in  the  course  of 
defervescence,  when  its  demands  are  imperious  and 
dangerous. 

According  to  Vaquez,  the  anorexia  is  mainly  due  to 
the  insufficient  diet  to  which  the  patients  are  restricted. 

Thirst  is  complained  of.  There  is  a  bitter  taste  in 
the  mouth.  The  salivary  secretion  is  diminished. 
The  restricted  diet,  fever  and  diarrhosa  are  factors  in 
the  diminution  of  these  secretions.  P.  Merklen  and 
Milhit,  however,  have  reported  a  case  of  abundant 
ptyalism  followed  by  sialorrhoea,  with  painless  bilateral 
parotid  and  submaxillary  swelling. 

At  the  onset  and  during  the  first  few  days  of  the 
disease  the  tongue  may  be  broad  and  flabby,  and  show 
the  marks  of  the  teeth  at  its  edges.  It  soon  becomes 
narrow,  tapering  and  more  or  less  pointed.  The 
epithelial  covering  disappears  at  the  tip  and  edges,  so 
that  the  central  part,  which  remains  white  or  yellowish 
white,  is  surrounded  by  a  bright  red  zone  placed  like 
an   isosceles    triangle    with   its    base    posteriorly.     In 

26 


DIGESTIVE  SYSTEM  27 

other  cases,  on  the  contrary,  the  coating  disappears  from 
the  centre  of  the  organ,  which  then  projects  hke  a 
red  V  into  the  middle  of  the  white  zone  (Jaccoud). 
When  the  course  of  the  disease  is  normal,  and  devoid  of. 
gravity,  the  tongue  retains  this  appearance.  When  the 
disease  lasts  longer  and  assumes  a  more  severe  form, 
the  redness  of  the  tip  and  edges  becomes  more  marked, 
a  red  punctation  appears  at  these  points  and  the 
central  coating  gets  thicker.  Lastly,  in  the  grave 
forms  with  a  severe  "  typhoid  state,"  the  tongue  gets 
dry  and  assumes  an  appearance  which  has  given  it 
the  name  of  "  roasted  tongue,"  "  grilled  tongue,"  or 
"  parrot's  tongue."  It  becomes  retracted,  hardened 
and  shrivelled,  its  movements  are  difficult,  uncertain 
and  painful.  Its  thick  coating  becomes  brown  or 
blackish,  crusted  and  cracked ;  it  is  formed  by  dried 
epithelial  cells  and  mucus,  and  coloured  by  the  blood 
which  has  oozed  from  the  cracks.  The  lips  become 
dry,  cracked  and  covered  with  sordes.  When  the 
typhoid  state  is  established  the  teeth  become  covered 
with  a  similar  coating.  In  very  rare  cases  the  gums 
are  the  seat  of  haemorrhage. 

The  soft  palate,  uvula,  tonsils  and  pharynx  take  on 
a  red  tint  and  become  covered  with  a  brown  coat. 

In  severe  attacks  various  forms  of  sore  throat  are 
seen  as  complications,  such  as  tonsillitis,  diphtheria  and 
gangrenous  angina. 

Thrush  is  fairly  often  observed.  It  appears  on  the 
soft  palate,  sometimes  on  the  back  of  the  pharynx, 
almost  always  on  the  pillars  and  tonsils,  rarely  on  the 
cheeks  and  tongue,  and  hardly  ever  on  the  gums  and 
lips  ;  sometimes  it  covers  the  uvula,  and  is  accompanied 
by  extreme  dysphagia.  It  yields  to  treatment,  but 
recurs  with  an  exasperating  obstinac3^ 

R.  Tripier,  Devic,  Johanno,  Letulle  and  others  have 
dwelt  on  the  appearance  of  bucco -pharyngeal  ulcera- 
tions in  typhoid  fever.  These  isolated  or  multiple 
ulcerations,  apparently  due  to  local  infection  by  the 
pathogenic  flora  of  the  mouth,  may  be  found  on  the 
tongue,   lips   and   cheeks,  soft   palate,  uvula,   in   the 


28    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

gingivo -labial  fold  and  at  the  frsenum,  and,  in  excep- 
tional cases,  on  the  posterior  pillars. 

In  addition  to  these  ulcerations  there  are  others, 
noted  for  the  first  time  by  Bouveret  in  1876  and  called 
"  Duguet's  ulcerations."  They  are  to  be  seen  in  one 
out  of  five  cases.  They  really  constitute  a  symptom 
and  not  a  complication  of  typhoid  fever.  Their  seat 
of  predilection  is  on  the  anterior  pillars  of  the  palate. 

They  are  fairly  often  situated  symmetrically  on  the 
two  palatal  pillars,  where  they  appear  in  the  form  of 
a  whitish  or  ashy  grey  patch,  slightly  oval  in  shape, 
running  obliquely  downwards  and  outwards,  with  their 
long  axis  parallel  to  that  of  the  corresponding  pillar, 
and  measure  six  to  eight  mm.  in  diameter.  On  their 
surface  is  to  be  found  a  little  mucus,  which  is  easily 
removed,  leaving  an  almost  normal  mucous  membrane 
which  does  not  bleed,  is  not  indurated,  and  is  of  a 
yellowish  grey  or  grey  pink  colour.  The  ulceration  is 
shallow,  its  edges  are  regular  and  surrounded  with  a 
small  red  area  of  congestion. 

On  the  edges  of  the  tongue  may  be  seen  ulcers  of  a 
different  appearance,  as  they  are  deeper  and  their 
edges  are  sharply  cut.  The  mucous  membrane  sur- 
rounding them  is  swollen  and  bleeds  readily.  They 
are  specially  situated  at  points  which  are  subject  to 
pressure  or  the  action  of  the  teeth,  whether  in  the  dorsal 
or  lateral  decubitus. 

They  are  kept  up  by  the  dryness  of  the  mouth  and 
prolonged  immobilisation  resulting  from  the  rarity  of 
movements  of  mastication  and  deglutition,  and  lastly 
by  the  local  infection  caused  by  the  microbial  flora 
of  the  buccal  cavity.  They  are  absolutely  painless, 
have  hardly  any  effect  on  the  neighbouring  lymph 
glands,  and  are  most  frequently  met  with  in  severe 
forms  of  typhoid  fever. 

The  ulceration  of  the  palatal  pillars  appears  before 
the  beginning  of  the  second  week,  at  the  same  period 
as  the  lenticular  rose  spots. 

They  are  characteristic  enough  to  confirm  a  diagnosis 
of  typhoid  fever. 


DIGESTIVE  SYSTEM  29 

Very  rare  cases  occur  in  which,  apart  from  the  fever, 
the  only  symptom  referable  to  the  digestive  tract  has 
been  this  ulceration  of  the  pillars,  the  patients  having 
had  no  meteorism,  diarrhoea  or  nervous  symptoms. 
As  they  generally  disappear  at  the  same  time  as  the 
fever,  they  serve  to  a  certain  extent  as  a  guide  to  the 
course  of  the  disease.  Their  persistence  may  herald 
a  relapse  ;  while  their  disappearance,  even  if  it  does  not 
eliminate  the  possibility  of  a  relapse,  is  of  favourable 
prognosis,  the  relapse  being  usually  mild  (Devic). 

The  practical  importance  of  looking  for  these  ulcers 
is  obvious,  possessing  as  they  do  the  value  of  a  specific 
sign,  with  the  exception  of  the  lingual  ulcers,  which 
have  been  noted  in  other  acute  diseases. 

Louis  has  described  pharyngeal  ulcers  which  appear 
late  (third  or  fourth  week) ;  they  are  multiple  and 
deep,  and  situated  at  the  lower  part  and  sides  of  the 
pharynx,  where  they  cannot  be  seen  by  the  unaided 
eye.  Their  course  is  generally  insidious,  but  they  may 
be  the  starting-point  of  more  serious  complications, 
especially  retro -tonsillar  or  retro -pharyngeal  abscesses. 
They  may  also  cause  oedema  of  the  glottis. 

Gastric  Symptoms. — Pain  and  tenderness  on 
pressure  on  the  epigastrium  are  very  frequent,  especially 
at  the  onset.  They  may  or  may  not  be  accompanied 
by  vomiting. 

It  is  also  at  the  onset  of  typhoid  fever  that  vomiting 
is  observed  in  the  adult,  and  still  more  frequently  in 
children. 

It  is  caused  by  a  feed  or  a  dose  of  medicine.  As  a 
rule  the  patients  have  a  sense  of  fulness  and  tension, 
with  nausea  and  distaste  for  food.  At  the  height  of  the 
disease  uncontrollable  vomiting  may  be  caused  by  the 
absorption  of  very  small  quantities  of  fluid;  and  may 
even  be  complicated  by  hsematemesis. 

When  it  occurs  in  convalescence,  vomiting  may 
merely  be  a  sign  of  indigestion,  or  herald  a  relapse.  It 
is  rarer  in  patients  who  have  not  been  subjected  to  a 
rigorous  diet  throughout  the  febrile  period  (Jaccoud). 
The  best  treatment  at  this  time  is  to  give  them  solid 


30    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

food  (Trousseau).  Less  frequently  the  vomiting  is 
due  to  ulcerative  lesions  of  the  stomach  and  degenera- 
tion of  the  glandular  cells  of  the  epithelium,  which 
have  not  retained,  or  have  been  unable  to  recover,  the 
integrity  of  their  functions. 

Intestinal  Symptoms. — Abdominal  pain  and  ten- 
derness are  frequent  but  not  constant  symptoms. 
They  are  rarely  spontaneous  ;  pressure  over  most  of 
the  intestine  is  painless,  but  on  the  right  iliac  fossa  it 
causes  almost  always  a  characteristic  pain,  sometimes 
severe  enough  to  provoke  a  grimace,  a  cry  or  a  move- 
ment of  defence  on  the  part  of  the  patient,  however 
prostrate  he  may  be.  This  sjanptom  is  a  more  or  less 
early  one  ;  it  may  persist  until  convalescence,  or  re- 
appear at  that  period  as  the  result  of  constipation  or 
an  error  of  diet.  The  pain  may  be  found  especially  at 
MacBurney's  point,  and  reveals  the  share  taken  by  the 
ileum  and  appendix  in  the  localisation  of  the  infective 
process. 

Meteorism  is  almost  constant.  It  may  be  present 
from  the  onset,  but  as  a  rule  it  is  not  definitely  appre- 
ciable before  the  end  of  the  first  week,  and  becomes 
marked  in  the  course  of  the  second.  When  the  intes- 
tine contains  only  a  little  gas,  the  abdomen  assumes 
a  special  shape.  It  is  distended  transversely.  The 
umbilicus  is  very  often  seen  to  project.  The  consis- 
tency is  elastic  on  palpation ;  the  resonance  of  the 
abdomen  is  exaggerated  on  percussion.  In  extreme 
cases,  with  an  enormous  quantity  of  gas  in  the  intestine, 
the  intestinal  distension  becomes  generalised,  the  thorax 
becomes  broadened  at  the  base,  the  respiratory  action 
of  the  diaphragm  is  interfered  with,  and  a  more  or  less 
serious  pulmonary  stasis  ensues.  The  frequency  and 
intensity  of  the  meteorism  are  related  to  the  gravity  of 
the  disease  (Jenner,  Louis,  Murchison). 

Gurgling. — In  a  large  number  of  cases  a  more  or  less 
marked  gurgling  is  observed  when  pressure  is  made 
abruptly  in  the  right  iliac  region.  This  examination 
should  be  made  with  great  care,  for  any  injury  to  a 
distended  and  ulcerated  intestine  should  be  avoided. 


DIGESTIVE  SYSTEM  31 

A  good  and  prudent  method  of  investigating  the 
presence  of  gurghng  is  to  employ  bimanual  palpation, 
using  each  hand  in  turn. 

According  to  Jaccoud,  gurgling  merely  indicates 
that  the  patient  has,  or  has  just  had,  diarrhoea.  It 
possesses  diagnostic  value  only  when  it  is  accompanied 
by  other  specific  symptoms,  and  if  the  patient  has 
no  diarrhoea,  and  has  not  been  given  an  enema  or  a 
purgative. 

"  Diarrhoea  is  the  rule  in  enteric  fever  and  constipa- 
tion the  exception."  Murchison's  formula  is  perhaps 
too  absolute.  Although  one  may  have  observed 
certain  cases  of  an  ambulatory  type  in  which  the 
patients  complained  of  diarrhoea  only,  the  date  of 
appearance  and  duration  of  the  diarrhoea  are  so  variable 
that  this  symptom  is  of  little  help  in  diagnosis.  It 
serves,  however,  to  confirm  the  diagnosis  in  certain 
cases  by  the  special  characters  which  it  presents. 

The  diarrhoeic  stools  in  typhoid  fever  are  liquid  and 
of  yellow  ochre  or  melon-juice  colour.  They  leave  a 
yellowish  stain  on  the  sheets,  surrounded  by  a  broad 
zone  of  a  faint  pink  colour.  Their  reaction  is  alkaline, 
their  odour  sometimes  foetid  and  sometimes  musty. 
On  standing  they  leave  a  flaky  sediment,  and  may 
contain  blood.  Their  evacuation  is  not  accompanied 
by  colic  or  tenesmus. 

Diarrhoea  may  be  present  from  the  onset  of  the 
disease,  but  usually  the  patient  is  constipated.  After 
a  purgative  the  stools  are  mashy  and  unformed,  and 
rapidly  become  liquid.  Their  frequency  is  very  vari- 
able according  to  the  patient.  Usually  they  are  not 
very  numerous  at  the  onset  (three  or  four  in  the 
twenty-four  hours),  and  the  maximum  number  is 
reached  towards  the  middle  or  end  of  the  second  week, 
when  they  may  amount  to  ten,  twelve  or  twenty  in  the 
twenty-four  hours.  In  such  cases,  which  indicate  the 
severity  of  the  infection  and  are  related  to  the  gravity 
of  the  disease,  the  diarrhoea  may  become  an  actual 
danger  owing  to  the  amount  of  water  which  it  removes 
from  the  system.     The  patient's  face  grows  pale,  his 


32     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

features  are  drawn,  his  skin  grows  dry,  his  peripheral 
temperature  falls,  his  pulse  becomes  frequent  and 
small,  and  collapse  may  ensue.  The  discharge  of 
faeces  may  be  involuntary,  indicating  a  profound  state 
of  prostration,  and  causing  an  erythema  of  the  buttocks 
and  over  the  sacrum. 

The  diarrhoea  usually  disappears  at  the  end  of  the 
fastigium  or  at  the  beginning  of  convalescence.  It  is 
not  exceptional,  however,  to  see  it  cease  rapidly  and  be 
replaced  by  an  obstinate  constipation,  which  lasts  until 
the  end  of  the  fastigium.  Then,  as  a  rule,  the  diar- 
rhoea returns,  and  sometimes  continues  till  the  end  of 
convalescence. 

In  very  rare  cases  constipation  is  more  persistent 
and  lasts  throughout  the  disease. 

Intestinal  haemorrhage. — Intestinal  haemorrhage 
is  an  important  symptom.  It  may  be  one  of  the 
early  signs  of  a  special  form  of  typhoid  fever  called 
hcemorrhagic.  It  is  then  of  a  severe  prognosis.  Some- 
times it  is  slight  and  appears  towards  the  tenth  or 
twelfth  day  of  disease.  But  more  frequently  it  results 
from  the  opening  of  an  arteriole  in  an  ulcer  or  erosion 
of  a  vessel  by  separation  of  a  slough,  in  which  case  it 
occurs  towards  the  fifteenth  or  twentieth  day.  It 
may  be  later  (thirty-third,  forty -fourth,  forty -ninth 
day).  It  is  rare  in  the  child,  uncommon  in  the  ado- 
lescent (twelve  to  fifteen  years),  and  is  more  frequent  in 
the  adult  and  in  certain  epidemics.  Diabetes  preced- 
ing typhoid  fever  seems  to  predispose  to  haemorrhage, 
owing  to  the  arterial  hypertension  which  is  the  rule  in 
diabetes  (Teissier). 

Late  haemorrhage,  especially  that  occurring  at  the 
end  of  the  third  week,  appears  with  equal  frequency 
among  patients  with  diarrhoea  or  constipation.  The 
quantity  of  blood  lost  may  vary  from  a  few  drops  to 
several  litres.  Sometimes  the  intestinal  haemorrhage 
is  fulminating,  and  causes  death  before  blood  has 
appeared  in  the  stools. 

In  such  cases  one  may  be  guided  by  a  sudden  fall 
of  temperature,  a  syncopal  attack,  an  almost  instan- 


DIGESTIVE  SYSTEM  33 

taneous  decrease  in  the  size  of  the  spleen,  a  transient 
rise  of  the  blood-pressure  (Teissier),  an  increase  in  fre- 
quency of  the  pulse  (Trousseau),  and  a  disappearance 
of  dicrotism  of  the  pulse  (Bouchard). 

But  as  a  rule  the  blood  appears  externally.  When  it 
is  scanty,  microscopical  examination  is  necessary  to 
reveal  it.  Spectroscopical  examination  must  also  be 
employed  when  this  method  is  possible.  The  phenol- 
phthalein  reaction  (Meyer's  reaction)  is  too  uncertain, 
and  should  not  be  recommended  (Hugounencq-Labat). 
The  same  applies  to  the  reactions  with  benzidine  and 
tincture  of  guiacum. 

The  blood  often  appears  in  the  form  of  red  streaks. 
When  present  in  larger  quantity,  it  gives  the  stools  the 
crimson  appearance  of  normal  blood ;  or,  if  it  has  been 
some  time  in  the  intestine,  its  colour  changes  to  that  of 
sepia,  pitch  or  tar. 

The  general  symptoms  of  intestinal  haemorrhage 
vary  considerably,  according  to  the  quantity  of  blood 
lost.  In  the  case  of  small  haemorrhages  there  are  no 
symptoms. 

When  the  loss  of  blood  is  greater,  or  the  haemorrhage 
is  moderate  in  amount  but  repeated,  the  patient 
becomes  pale  and  complains  of  giddiness,  ringing  in  the 
ears  and  tendency  to  syncope.  The  temperature  falls 
in  proportion  to  the  amount  of  the  haemorrhage.  But 
this  fall  is  only  temporary,  and  the  thermometer  soon 
rises  to  a  higher  level  than  before  the  fall.  Late  haemor- 
rhages often  indicate  a  fatal  prognosis  (30-35  per  cent.), 
with  rapid  termination ;  in  an  hour  in  one  of  Trous- 
seau's cases,  and  even  in  a  few  minutes  (H.  Vincent). 
Though  some  writers  have  regarded  intestinal  haemor- 
rhage in  typhoid  fever  as  a  favourable  symptom,  actual 
facts  and  statistics  prove,  on  the  contrary,  that  it  is  a 
serious  symptom,  since  44-3  per  cent,  of  the  patients 
with  this  symptom  succumb  (Homolle). 

Intestinal  Perforation. — Intestinal  perforation 
in  typhoid  fever  may  be  single  or  multiple,  and  occur 
in  mild,  ambulatory  forms  as  well  as  in  severe  attacks, 
£^nd  more  rarely  in  the  course  of  relapses.     Their  seat 


34     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

of  predilection  is  the  ileum  in  its  last  40-50  cm.,  espe- 
cially in  the  neighbourhood  of  the  ileo-csecal  valv^,  the 
appendix  and  large  intestine  as  far  as  the  rectum. 

Perforation  is  more  frequent  in  men  than  in  women. 
It  is  rather  rare  in  children.  It  occurs  generally  at 
the  end  of  the  second  week,  or  in  the  course  of  the  third, 
and  even  later.  The  efforts  which  patients  make  in 
raising  themselves  or  using  the  bedpan  are  sometimes 
responsible  for  it. 

Intestinal  perforation  is  often  heralded  by  premoni- 
tory signs,  to  which  some  writers  attribute  very  great 
value  and  others  very  little. 

Triboulet  thinks  that  profuse  diarrhoea  accompanied 
by  blood,  even  in  slight  traces,  has  a  very  great  import- 
ance in  enabling  one  to  foretell  intestinal  perforation. 

Meteorism  should  be  interpreted  with  much  reserve, 
for  perforations  have  been  seen  to  occur  in  collapsed 
intestines,  and,  on  the  other  hand,  very  pronounced 
abdominal  distension  has  been  seen  when  there  was 
no  perforation  (Cassaet  and  Duperie). 

Intestinal  perforation  is  revealed  by  peritonitis, 
which  may  run  its  course  in  one  of  two  ways  :  acute 
or  hyperacute  peritonitis,  or  peritonitis  with  attenuated 
signs,  and  even  latent  peritonitis.  In  the  majority 
of  cases  the  onset  is  sudden  and  unexpected.  The 
patient  feels  a  very  violent  spontaneous  pain  which 
compels  him  to  cry  out^  and  may  even  make  him  lose 
consciousness.  Without  any  obvious  cause  he  feels 
a  tearing  or  stabbing  sensation  in  the  lower  part  of  the 
belly  on  the  right  hand  side,  which  may  radiate  along 
the  spermatic  cord  to  the  testicle  and  rectum  and  then 
become  generalised.  Sometimes  the  pain  is  less  violent. 
It  may  be  confined  to  a  rather  painful  spot,  over  which 
slight  hypersesthesia  is  found  on  palpation. 

Usually  there  is  muscular  contracture,  which  is  at 
first  localised  to  the  lower  part  of  the  recti,  especially 
the  right  rectus,  and  then  rapidly  extends  all  over  the 
abdomen,  which  may  assume  a  board-like  hardness 
and  show  a  scaphoid  retraction.  The  patient  usually 
has  a  severe  attack  of  shivering ;    his  face  is  drawn, 


DIGESTIVE  SYSTEM 


35 


his  voice  lost,  the  nose  pinched,  his  eyes  sunken  and 
surrounded  by  dark  rings,  and  the  extremities  cold. 
The  temperature  shows  a  sudden  drop,  falls  even  below 
normal  (Fig.  2),  and  remains  so  in  the  cases  that  are 


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.^ 

«. 

Fig.  2. — Hospital  orderly.  Typhoid  fever^  25th  day  of  disease. 
Signs  of  perforative  peritonitis.  Cyanosis,  hypothermia.  Tem- 
perature 92-6°.     Recovery  without  operation. 


rapidly  fatal,  or  rises  again  a  few  hours  later,  but  slowly 
arid  hesitatingly,  in  a  very  different  way  from  the  sudden 
ascent  observed  after  intestinal  hsemorrhage.  This 
hypothermia  is,  unfortunately,  not  constant,  being 
sometimes  replaced  by  hyperthermia.     Lastly,  in  some 


36    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

cases  the  onset  of  peritonitis  is  not  accompanied  by  any 
change  of  temperature. 

The  pulse  may  become  frequent,  small  and  feeble, 
or,  on  the  contrary,  become  slow.  The  patient  may 
have  nausea  and  bilious  vomiting,  which  is  sometimes 
green  and  porraceous  and  appears  early  or  late.  There 
may  be  hiccough  ;  micturition — when  anuria  is  not 
present — may  be  painful.  This  vesical  pain,  which 
has  been  noted  by  Sieur,  Picque  and  Delbet,  is  a  good 
sign  if  it  occurs  regularly. 

The  stools  are  much  diminished,  if  not  actually 
suppressed.  This  symptom,  which  has  been  noted  by 
Sieur,  although  a  late  one,  has  all  the  more  value,  as 
at  the  period  of  perforation  typhoid  patients  usually 
have  numerous  stools. 

Inspiration  of  the  costal  type  has  been  noted,  as  well 
as  disappearance  of  the  liver  dulness. 

According  to  Levaschoff,  on  auscultation  a  peculiar 
sound  is  heard  due  to  the  passage  of  gas  into  the  abdo- 
minal cavity.  Brown's  signs  have  been  rarely  met  with„ 
and  their  investigation  may  be  extremely  dangerous 
for  the  patient.  We  will  mention  them,  however,  for 
the  sake  of  completeness. 

(a)  The  patient  lying  in  the  dorsal  decubitus,  one 
finds  by  palpation  the  point  at  which  the  maximum 
pain  is  felt.  This  point  having  been  determined,  if 
the  patient  be  made  to  lie  on  his  left  flank,  the  painful 
spot  becomes  displaced  at  the  same  time  as  the  intes- 
tinal mass,  being  shifted  from  1|-  to  2  cm.  in  twenty 
to  thirty  minutes. 

(6)  If  a  stethoscope  be  suddenly  applied  to  this  point, 
fine  crepitations  are  heard  which  indicate  a  localised 
peritonitis. 

The  sudden  appearance  of  hyperleucocytosis  in  the 
blood  is  inconstant. 

It  is  thus  clear  that  there  is  no  constant  sign  of 
intestinal  perforation.  We  may,  however,  say  with 
Faisans  and  Flandin  that  "  we  ought  to  think  of  per- 
foration of  the  intestine  when  a  pain  occurs  without 
any  definite  reason  in  a  typhoid  patient  in  the  third 


SPLEEN  37 

week,  whether  it  be  a  stabbing  pain  or  a  dull  pain,  and 
whether  situated  at  the  umbilicus  or  in  the  right  iliac 
fossa."  The  presence  of  certain  other  symptoms  will 
confirm  the  diagnosis  ;  but  one  should  always  remember 
that  perforation  may  be  insidious  and  develop  almost 
without  symptoms,  and  that  "  the  advent  of  perforation 
may  likewise  be  latent  in  consequence  of  the  patient 
being  delirious  or  unconscious ;  the  prostration  being 
accounted  for  by  the  severity  of  the  fever,  and  the 
ordinary  symptoms  of  peritonitis  being  absent " 
(Murchison). 

Spleen 

Enlargement  of  the  spleen  is  almost  constant.  It 
begins  in  the  middle  of  the  first  week  and  increases 
until  the  end  of  the  second.  It  is  an  acute  enlarge- 
ment of  infective  origin,  which  may  be  accompanied 
by  abscesses  and  haemorrhages  into  the  parenchyma, 
and,  in  exceptional  cases,  end  in  rupture  of  the  organ. 
At  first  the  spleen  is  firm  and  hard,  but  later  it  becomes 
soft  and  diffiuent. 

How  are  we  to  examine  the  spleen,  and  when  can 
we  say  that  it  is  increased  in  size  ?  Normally  it  is 
situated  behind  the  border  of  the  false  ribs,  and  is  not 
accessible  to  palpation.  Its  outer  and  convex  surface 
corresponds  to  the  ninth,  tenth  and  eleventh  ribs. 
Its  anterior  border  is  thin  and  does  not  pass  beyond 
a  line  drawn  from  the  sterno -clavicular  joint  to  the 
anterior  extremity  of  the  eleventh  rib  (sterno -costal 
line).  It  may  be  examined  by  percussion  and  palpa- 
tion, which  should  always  be  carried  out  gently. 
The  enlargement  is  more  readily  detected  on  percus- 
sion than  on  palpation.  Percussion  should  be  made 
gently  with  little  taps  and  concentrically,  starting  from 
a  sonorous  region  towards  the  zone  presumed  to  be 
splenic,  keeping  the  ear  close  to  the  percussing  finger. 
In  practice  a  spleen  should  be  considered  large  which 
measures  more  than  5  cm.  in  the  largest  diameter  of 
its  dulness.  It  may  reach  nine,  ten  or  twelve  cm.  and 
more  in  its  largest  axis. 


38    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Respiratory  System 

The  respiratory  movements  are  usually  accelerated, 
apart  from  any  pulmonary  complications.  They 
generally  vary  with  the  pulse  and  temperature. 

The  nasal  fossce  are  dry ;  epistaxis,  varying  in  fre- 
quency and  gravity,  may  occur  at  any  period  of  the 
disease.  Apart  from  cases  in  which  it  is  only  one  of 
the  manifestations  of  hsemorrhagic  typhoid  fever  and 
those  which  are  of  exceptional  gravity  owing  to  its 
profuseness,  epistaxis  has  no  prognostic  significance. 

Typhoid  fever  very  frequently  causes  lesions  of  the 
larynx,  the  two  commonest  of  which  are  ulceration 
of  the  epiglottis  and  laryngo -typhoid.  The  patient 
usually  has  a  little  hoarseness  or  aphonia,  with  dys- 
phagia, especially  if  the  epiglottis  is  the  seat  of  the 
ulceration,  and  the  larynx  is  more  or  less  tender  on 
pressure. 

In  the  course  of  ataxic  or  adynamic  fevers  with 
bedsores  and  multiple  abscesses,  more  important 
lesions  are  found,  consisting  in  necrosis  of  the  larynx, 
or  laryngo-typhoid.  After  a  period  of  hoarseness  the 
voice  becomes  weak,  the  respiration  noisy  and  difficult, 
and  deglutition  painful.  The  patient  has  a  hoarse 
and  toneless  cough,  and  cannot  speak  above  a  whisper. 
All  these  sj^^mptoms  become  rapidly  more  pronounced. 
The  cough  becomes  croupy,  the  expectoration  purulent, 
or  blood-stained,  and  may  contain  fragments  of  necrosed 
cartilage,  the  breath  is  foetid,  the  dysphagia  increases, 
and  pressure  on  the  larjaix  is  intolerably  painful. 
Respiration  becomes  more  and  more  difficult  and  is 
accompanied  by  a  noisy,  guttural  rhonchus,  which  is 
sometimes  "  deadened,  or  rough  and  harsh  like  the 
sound  of  a  bass  string  "  (Bouillaud).  Then  occur  an 
attack  of  suffocation  with  cyanosis,  cold  and  clammy 
sweat,  terrible  anxiety,  and  cardiac  failure.  The 
attacks  may  be  repeated,  being  provoked  by  the  mere 
application  of  a  tongue  depressor  or  laryngoscopic 
mirror,  or  the  absorption  of  a  small  quantity  of  fluid. 
In  the  intervals  between  the  attacks  the  patient  is  in  a 


RESPIRATORY  SYSTEM  39 

state  of  asphyxial  collapse.  In  spite  of  a  continuous 
dyspnoea,  the  suffocative  attacks  may  be  absent  during 
the  day,  as  an  effort  of  the  will  is  sufficient  to  maintain 
respiration,  but  at  night  during  sleep,  when  the  will 
is  no  longer  active,  the  attacks  begin. 

The  patient  may  die  in  an  attack,  or  as  the  result  of  a 
sudden  spasm  of  the  glottis. 

If  he  escapes  death  by  asphyxia,  he  may  have 
abscesses  in  the  neck,  necrosis  of  the  cartilages,  peri- 
laryngeal phlegmons,  etc. 

Bronchitis  is  very  frequent  in  typhoid  fever.  It 
generally  appears  at  the  end  of  the  first  week,  and  is 
revealed  by  sibilant  rales  mixed  with  a  few  mucous 
rales  scattered  here  and  there  throughout  the  chest, 
but  predominant  at  the  bases.  The  cough  and  expec- 
toration have  no  special  characters.  Sometimes  the 
lesions  of  bronchitis  are  complicated  by  a  slight  degree 
of  pulmonary  congestion,  with  spasmodic  cough  and 
dyspnoea. 

At  the  height  of  the  disease,  towards  the  third  or 
fourth  week,  there  may  be  engorgement  and  spleniza- 
tion  of  the  bases  without  definite  physical  signs. 

Pulmonary  cedema  may  also  be  found,  indicating 
typhoid  nephritis.  But  the  most  frequent  pulmonary 
complication  is  undoubtedly  hroncJio-pneumonia,  which 
may  be  present  in  7  per  cent,  of  the  cases  (Joftroy), 
and  even  11  per  cent  (Nobecourt  and  E.  Peyre). 

Usually  a  late  event,  it  develops  insidiously,  and 
should  always  be  regarded  as  serious  owing  to  its 
possible  modes  of  termination,  viz.  extension  of  the 
process,  phenomena  of  infection,  suppuration  and 
gangrene. 

Pneumonia  rarely  occurs  before  the  third  or  fourth 
week.  In  rare  cases  it  may  appear  sooner  and  be 
taken  for  the  initial  disease.  It  has  been  described 
under  the  name  of  pneumo-typlioid. 

At  the  height  of  the  disease  pneumonia  singularly 
aggravates  the  condition  of  the  typhoid  patient.  In 
convalescence  it  has  not  the  same  significance,  as  a 
rule. 


40    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Simple  hcemorrhagic  infarcts  are  fairly  frequent ; 
foci  of  pulmonary  apoplexy  are  revealed  only  by 
haemoptysis. 

Lastly,  embolism  of  the  pulmonary  artery,  multiple 
abscesses  and  pulmonary  gangreiie  have  been  recorded. 

Pleura. — Pleural  complications  are  far  from  rare 
in  typhoid  fever  (2-4  per  cent,  according  to  E.  Jolt- 
rain  and  G.  Petitjean).  They  are  even  more  frequent 
than  is  supposed,  if  they  are  looked  for  methodically. 
They  may  be  observed  at  the  onset  of  the  disease,  and 
they  constitute  that  special  form  which  has  received 
the  name  of  pleuro-typJioid. 

But  it  is  at  the  height  of  the  disease,  and  especially 
in  convalescence,  that  they  usually  appear. 

Dry  pleurisy  in  typhoid  fever  has  no  clinical  history. 
Serous  pleurisy  chiefly  occurs  at  the  onset. 

Cytological  examination  of  the  centrifugalised  fluid 
shows  an  abundance  of  desquamated  endothelial  cells 
and  neutrophil  polymorphonuclears  or  eosinophils.  In 
some  cases  the  number  of  lymphocytes  is  very  high 
and  indicates  a  latent  tuberculous  infection,  which 
has  been  made  active  by  the  typhoid  bacillus  (H. 
Vincent).  Cultivation  of  the  pleural  fluid  often  shows 
the  typhoid  bacillus. 

Hoimorrhagic  pleurisy  may  be  observed  at  the  begin- 
ning of  convalescence.  It  is  due  either  to  latent  tuber- 
culosis or  to  special  virulence  in  the  strain  of  the  typhoid 
bacillus . 

The  last  view  seems  to  be  confirmed  by  the  fact  that 
pure  cultures  of  the  typhoid  bacillus  injected  into  the 
pleura  of  guinea-pigs  have  produced  an  abundant 
hsemorrhagic  effusion.  Pleurisy  may  be  hsemorrhagic 
from  the  first,  and  then  purulent,  and  finally  hsemor- 
rhagic  again.  When  it  is  localised  it  may  be  hsemor- 
rhagic  in  one  part  with  a  B.  coli  of  attenuated  virulence, 
and  purulent  in  another  part  with  the  typhoid  bacillus 
(Macaigne  and  Thery). 

The  effusion  is  scanty  as  a  rule  and  situated  on  the 
left.  Its  appearance  and  development  are  generally 
insidious,  without  pain  in   the  side,  dyspnoea,  or  rise 


CIRCULATORY  SYSTEM  41 

of  temperature,  and  the  diagnosis  can  be  made  by 
exploratory  puncture  only. 

In  addition  to  the  presence  of  a  large  number  of  red 
cells,"  lymphocytes  or  neutrophil  polymorphonuclears, 
which  vary  in  number  according  to  the  case,  cytological 
examination  of  the  hsemorrhagic  effusion  shows  a 
large  proportion  of  large  endothehal  cells,  isolated  or  in 
groups,  which  are  to  be  found  as  long  as  the  effusion 
lasts  (Widal,  Ravaut  and  Lemierre).  Vincent  found 
lymphocytosis  in  a  hsemorrhagic  pleurisy  due  to  typhoid 
bacilli.  In  Rosenthal's  case  the  initial  lymphocytosis 
gave  way  to  polymorphonucleosis.  In  Macaigne  and 
Thery's  case  pus  containing  typhoid  bacilli  showed  a 
very  high  polymorphonucleosis  with  the  cells  consider- 
ably damaged,  without  eosinophils  and  with  only  a 
few  mononuclears. 

These  effusions,  .  whether  serous,  sero -purulent  or 
hsemorrhagic,  do  not  present,  as  a  rule,  any  gravity. 
Usually  they  are  absorbed  spontaneously,  without 
puncture  and  without  leaving  any  trace.  It  is  not 
the  same  with  purulent  effusions,  which  may  end  in 
empyema,  an  interlobar  pleural  abscess,  or  a  vomica. 

Circulatory  System 

Pericarditis  and  endocarditis  are  fairly  rare  in 
typhoid  fever.  Ulcerative  endocarditis  with  the 
typhoid  bacillus  both  in  cultures  and  in  sections,  has 
been  recorded  (H.  Vincent). 

Myocarditis  is  extremely  common  in  the  course  of 
the  third  week.  It  is  very  important  to  look  for  it.  It 
is  observed  especially  in  the  graver  and  prolonged  forms, 
or  in  the  ataxo -adynamic  forms  with  hyperpyrexia. 
Myocarditis  is  revealed  at  its  onset  by  acceleration  and 
enfeeblement  of  the  heart-beat,  by  muffling  of  the  heart 
sounds,  especially  of  the  first  sound,  fall  in  the  blood- 
pressure  and  failure  and  irregularity  of  the  pulse. 

But  these  phenomena  are  soon  replaced  by  the 
foetal  or  tic-tac  rhythm  to  which  Huchard  has  given 
the  name  of  embryocardia. 


42    TYPHOW  FEVER  AND  PARATYPHOID  FEVERS 

In  this  case  the  two  silent  intervals  become  of  equal 
duration,  and  the  two  sounds  have  the  same  intensity 
and  the  same  tone.  There  is  at  the  same  time  tachy- 
cardia. The  pulse  becomes  frequent,  small  and  com- 
pressible, then  unequal,  irregular,  intermittent,  and 
sometimes  alternating  :  i.  e.  at  regular  intervals  a 
strong  and  normal  pulsation  succeeds  one  which  is 
small  and  inadequate.  At  this  stage  the  patient's 
urine  is  scanty  and  albuminous  ;  pulmonary  congestion 
may  be  noted. 

In  a  more  advanced  stage  the  cardiac  impulse  is 
replaced  by  an  indefinite  undulation  (Hayem). 

On  auscultation  there  is  considerable  weakening  of 
the  first  sound,  which  may  disappear  completely.  The 
second  sound  is  not  modified  in  the  majority  of  cases, 
but  it  may,  however,  be  reduplicated  and  get  weaker 
until  it  disappears  (Hayem).  One  may  hear  a  very 
soft  murmur,  meso  systolic  or  even  systolic  in  time, 
situated  at  the  apex  and  conducted  to  the  base. 

The  patient  complains  of  intense  dyspnoea  and  has  a 
distressing  air  hunger.  His  face  is  cyanosed  and  his 
eyes  wander.  His  temples  are  covered  by  a  cold,  clammy 
sweat.  The  lower  limbs  become  cedematous.  The 
pulse  becomes  feeble  and  cannot  be  counted. 

Soon  an  algid  collapse  develops,  which  may  be 
transient,  last  a  few  hours  and  disappear,  or  be  the 
cause  of  death,  simply  from  cardiac  insufficiency, 
without  asystole. 

On  other  occasions  the  patient  dies  suddenly  on 
making  a  simple  movement  or  slight  effqrt,  or  in  a 
syncopal  attack,  without  a  cry  or  complaint  of  any 
kind.  A  syncopal  attack  is  not  necessarily  fatal,  but 
in  cases  which  survive  it  aggravates  the  prognosis ; 
the  patient  will  often  develop  chronic  myocarditis, 
which  sooner  or  later  will  lead  to  asystole. 

It  is  necessary,  therefore,  to  make  a  systematic 
examination  daily  for  myocarditis.  Knowledge  of  this 
frequent  complication  is  of  the  utmost  importance  to 
the  practitioner. 


CIRCULATORY  SYSTEM  43 


Veins — Typhoid  Phlebitis.     Thrombo- 
phlebitis.    Phlegmasia  alba  dolens 

The  type  of  typhoid  phlebitis  is  the  phlebitis  of 
the  veins  of  the  lower  limb,  or  phlegmasia  alba  dolens. 
Due,  as  a  rule,  not  to  the  typhoid  bacillus,  but  to 
the  staphylococcus,  the  thrombosis  affects  principally 
the  femoral  vein,  less  frequently  the  saphenous  and 
popliteal.  It  is  raore  often  unilateral  than  bilateral, 
and  is  almost  always  situated  on  the  left.  Trousseau 
thought  it  was  rare,  Murchison  found  it  in  1  per 
cent.,  Hutinel  in  6  per  cent.,  Vincent  in  8-23  per 
cent,  among  340  cases  of  typhoid  fever,  and  Da 
Costa  in  12  per  cent.  Conner  says,  "If  we  can 
succeed  in  recognising  the  attenuated  forms,  it  will 
probably  be  found  in  10-15  per  cent." 

Phlebitis  is  a  complication  of  convalescence,  almost 
always  occurring  in  the  week  or  fortnight  following  the 
disappearance  of  the  fever. 

The  onset  is  sometimes  gradual,  sometimes  sudden, 
with  sharp  pain  and  pronounced  rise  of  temperature. 
The  signs  are  those  typical  of  phlebitis,  with  this 
difference,  that  the  hard  oedema  is  not  white  but 
is  accompanied  by  a  slight  redness.  Recovery  takes 
place  as  a  rule,  but  any  of  the  compHcations 
may  develop  which  have  been  noted  as  the  sequel  of 
any  venous  thrombosis,  such  as  varicose  veins,  oedema, 
gangrene,  pulmonary,  cardiac  or  renal  embolism,  and 
sudden  death. 

Conner  thinks  that  the  typical  symptoms  do  not 
appear  till  late,  when  the  venous  obliteration  is  an 
accomplished  fact.  He  also  regards  the  pleuro -pul- 
monary complications  of  typhoid  fever  as  embolic  in 
origin.  The  emboli  are  derived  from  friable  thrombi, 
recently  formed  in  veins  which  have  not  yet  been 
obliterated,  which  would  explain  why  their  manifesta- 
tions appear  before  the  typical  signs  of  phlebitis.  The 
typical  symptoms  of  these  embolisms  are — 

1.    An  almost  constant  pain  in  the  thorax,  almost 


44    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

invariably  at  the  onset,  appearing  suddenly,  and  situated 
in  the  lower  part  of  one  of  the  axillae. 

2.  Constant  cough,  with  occasionally  blood-stained 
expectoration  (45  per  cent.). 

3.  Oppression,  dyspnoea,  shivering  and  signs  of 
pleurisy,  with  or  without  effusion,  may  be  noted. 

4.  Finally,  Conner  insists  on  the  value  of  a  sign  which 
he  has  found  in  all  cases  of  confirmed  or  latent  phlebitis, 
viz.  pain  in  the  toes,  resulting  from  "  an  irritation  of 
the  plantar  nerves  due  to  a  periphlebitic  inflammation 
in  the  neighbourhood  of  the  thrombosed  veins  in  the 
region  of  the  heel." 

Perhaps  a  more  simple  explanation  would  be  peri- 
pheral neuritis. 

Arteries.  Typhoid  Arteritis. — Typhoid  fever 
occupies  the  first  rank  among  the  infections  which  are 
the  cause  of  arteritis.  Like  phlebitis,  this  arteritis 
is  usually  found  in  the  lower  limbs,  but,  unlike  phlebitis, 
chiefly  on  the  right  side.  The  posterior  tibial  is  the 
artery  most  frequently  affected,  and  then  the  femoral, 
popliteal,  anterior  tibial  and  dorsalis  pedis.  Then 
come  the  arteries  of  the  upper  limbs,  the  iliacs,  external 
carotid.  Sylvian,  etc.  Arteritis  of  the  limbs  hardly 
ever  occurs  before  the  end  of  the  third  week,  from  the 
thirteenth  to  forty-first  day  (Rendu),  or  even  up  to  the 
fifty-eighth  (Barie),  whereas  arteritis  of  the  visceral 
arterioles,  which  is  much  more  frequent,  is  generally 
observed  during  the  height  of  the  disease. 

The  typical  arteritis  of  typhoid  fever — viz.  that  in 
the  lower  limb — begins  with  a  pain  which  is  more  or 
less  acute  and  sudden,  but  is  always  situated  in  the 
course  of  the  arteries.  Sometimes  it  is  localised  in  the 
calf,  the  popliteal  space,  or  Scarpa's  triangle,  but  it  may 
occupy  the  whole  limb.  It  is  greatly  aggravated  by 
walking,  compression,  standing,  or  the  least  movement. 

The  amplitude  of  the  pulsation  in  the  affected  arteries 
is  very  much  diminished,  sometimes  even  the  pulsation 
is  entirely  suppressed.  The  lower  limb  affected  is 
first  of  all  swollen,  but  without  oedema  or  redness. 
Then  it  becomes  mottled  with  violet  patches,  areas  of 


CIRCULATORY  SYSTEM  45 

cyanosis,  and  even  purpuric  spots.  The  patient  suffers 
from  formication  and  other  uneasy  sensations  in  the 
leg,  which  grows  cold. 

The  artery  appears  in  the  form  of  a  hard  and  painful 
cord.  Finally,  dry  gangrene,  which  terminates  the 
process,  involves  elimination  of  the  mortified  tissues 
and  death.  In  rare  cases  venous  thrombosis  may  be 
observed  at  the  same  time  as  the  obliterative  arteritis 
(Patry). 

Cases  are  on  record  of  parietal  arteritis,  i.e.  partial 
arterial  obstruction,  or  narrowing  of  greater  or  less 
extent  of  the  lumen  of  the  vessel,  in  which  the  previous 
symptoms  are  attenuated  and  the  lesions  curable. 
When  the  arteritis  affects  other  vessels  than  those  of 
the  lower  limb,  the  gravity  of  the  terminal  gangrene  is 
due  to  the  functional  importance  of  the  organ  supplied 
by  the  affected  artery. 

Blood. — During  the  febrile  period  a  reduction  of 
70-80  per  cent,  in  the  amount  of  hcemoglobin  may 
occur,  and  in  grave  cases  it  may  fall  even  below  70 
per  cent.  The  number  of  red  blood  cells  is  slightly 
diminished  during  the  first  two  weeks  ;  a  shght  increase 
in  their  number,  however,  has  been  recorded.  On  the 
average  the  red  cells  number  from  4,000,000  to  5,000,000 
during  the  febrile  period.  At  the  time  of  defervescence 
there  is  a  sudden  diminution  of  the  red  cells.  In  severe 
forms  this  may  be  considerable  :  804,000  red  cells 
per  cubic  millimetre  (Henry). 

The  changes  in  the  corpuscles  are  of  the  ordinary  kind  : 
microcytes,  megalocytes  and  polychromasia.  After 
haemorrhage  some  nucleated  red  cells  have  been  seen. 

The  -colour  index  is  almost  normal.  Henocque  and 
Baudouin  have  seen  the  activity  of  reduction  for  oxy- 
hcemoglobin  fall  spectroscopically  to  0*20  during  the 
height  of  the  disease,  rising  to  0"50  in  convalescence 
and  to  0- 70-0- 80  on  recovery.  Pignatti  and  Morano 
have  seen  an  increase  in  the  f)iea7i  resistance  of  the 
red  cells  at  the  height  of  the  disease,  with  a  more  or 
less  sudden  return  to  normal,  and  sometimes  even 
diminution,  in  convalescence. 


46    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  absorptive  power  of  the  blood  for  oxygen  is 
diminished  (192-196  cc.  of  oxygen  for  1000  grm.  of 
blood  instead  of  240  cc).  The  leucocytes  have  formed 
the  object  of  numerous  researches.  It  is  well  known 
that  in  normal  conditions  very  sHght  causes  are  suf- 
ficient to  cause  variations,  not  only  in  the  total  number 
of  leucocytes,  but  also  in  the  differential  count.  It  is 
therefore  not  surprising  that  the  results  pubhshed  do 
not  admit  of  comparison  owing  to  the  extreme  variety 
of  the  cases,  comphcations  and  incidents  of  all  kinds, 
as  well  as  the  treatment,  which  may  modify  the  result 
of  the  examinations. 

Apart  from  differences  of  detail,  it  may  be  affirmed 
that  typhoid  fever  does  not  increase  the  number  of 
leucocytes.  It  may  even  cause  a  hiicopenia,  which 
disappears  rapidly  or  slowly,  once  and  for  all,  or  on 
several  occasions,  either  at  the  time  of  convalescence 
or  a  little  before. 

In  the  course  of  the  first  week  the  differential  count 
shows  an  excess  of  polymorphonuclears,  in  the  second 
and  third  weeks  there  are  Ijmiphocytosis  and  mono- 
nucleosis, with  disappearance  of  the  eosinophils .  At  the 
same  time  there  appears  in  half  the  cases  an  iodophil 
reaction  in  the  leucocytes,  but  we  beheve  that  its 
appearance  coincides  with,  the  onset  of  comphcations, 
especially  of  an  inflammatory  nature. 

From  the  prognostic  standpoint  the  examination 
of  the  blood  may  furnish  the  following  valuable 
information — 

1.  The  reappearance  of  the  eosinophils  indicates  the 
onset  of  convalescence  ^vithin  two  or  three  days. 

*2.  A  rapid  increase  in  the  number  of  leucocytes  may 
indicate  a  comphcation.  This  comphcation  is  of  an 
inflammatory  nature  when  the  increase  in  the  number 
of  the  leucocytes  is  accompanied  by  polymorpho- 
nucleosis,  with  an  iodophil  reaction. 

3.  A  rapid  and  very  pronounced  decrease  in  the 
number  of  leucocytes  indicates  an  aggravation  of  the 
disease,  especially  if  it  is  accompanied  by  a  diminution 
in  the  number  of  lymphocytes. 


CIRCULATORY  SYSTEM  47 

The  blood  platelets  diminish  in  number  until  only 
50  per  100,000  are  found  at  the  time  of  defervescence. 
Then  they  slowly  increase,  following  an  ascending 
curve,  which  attains  its  maximum  twelve  days  after  the 
end  of  defervescence  (Hayem). 

The  alkalinity  of  the  blood  rises  at  the  onset  of 
typhoid  fever,  and  then  undergoes  a  progressive 
diminution. 

The  coagulation  time  does  not  show  any  remarkable 
modifications  ;  it  is,  perhaps,  a  little  delayed. 

The  clot  is  soft,  forms  slowly,  sometimes  even  incom- 
pletely. The  amoumt  of  fibrin  varies  from  1  gm.  to 
3-7  gm.  per  1000,  and  sinks  in  proportion  to  the  gravity 
of  the  disease. 

Some  importance  has  been  attributed  to  the  investi- 
gation of  the  fibrin  network,  between  the  slide  and 
covershp,  according  to  Hayem 's  method.  The  absence 
of  the  fibrin  network,  or  the  slenderness  of  the  fibrin 
threads,  is  not  peculiar  to  typhoid  fever ;  they  are 
met  with  in  a  number  of  other  febrile  conditions,  and 
especially  in  the  eruptive  fevers  and  acute  miliary 
tuberculosis. 

The  serum  which  exudes  from  the  clot  varies  consider- 
ably :  it  is  abundant,  clear  and  lemon -yellow  when  the 
clot  is  well  formed,  and  its  retraction  is  normal ;  it  is 
somewhat  scanty,  and  of  a  reddish  colour  when  the 
clot  is  soft,  retracts  slowly  and  more  or  less  completely. 
It  may  be  lactescent. 

The  important  characteristic  of  the  blood  serum  in 
typhoid  is  the  property  which  it  possesses  of  agglutin- 
ating the  specific  bacillus  from  the  moment  of  invasion. 
It  is  upon  this  idea,  which  is  due  to  Widal,  that  the 
"  serum  diagnosis  "  of  typhoid  fever  is  founded. 

Reserving  for  our  special  chapter  on  the  laboratory 
diagnosis  of  typhoid  fever  a  description  of  the  technique 
of  the  serum  test  and  the  conclusions  to  be  drawn  there- 
from, we  will  confine  ourselves  here  to  a  consideration 
of  the  clinical  significance  of  agglutination.  Let  us 
state  first  of  all  in  what  it  consists.  The  phenomenon 
may  be  seen  both  microscopically  and  macroscopically. 


48    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

If  to  100  drops  of  a  young  culture  (24  hours)  of  the 
typhoid  bacillus  be  added  a  drop  of  typh6id  serum, 
in  a  few  minutes  the  microscope  will  show  that  the 
bacilli  have  lost  their  motility  and  are  grouped  in  more 
or  less  considerable  masses,  between  which  may  be 
seen  a  few  isolated,  but  motionless,  bacilli.  If  the  mix- 
ture has  been  made  in  a  small  tube  and  put  in  the 
incubator,  the  fluid,  which  was  turbid  at  first,  becomes 
clear,  and  whitish  flakes  become  deposited  at  the  bottom 
of  the  tube.  This  agglutination  reaction  is  speciflc ; 
that  is  to  say,  peculiar  to  the  typhoid  bacillus. 

Nevertheless,  the  serum  of  patients  suffering  from 
paratyphoid  A  can  agglutinate  indifferently  the  typhoid 
bacillus  and  the  paratyphoid  B  bacillus  (Sacquepee). 

The  serum  of  patients  suffering  from  paratyphoid 
fever  contains,  in  fact,  fairly  often  coagglutinins  and 
cosensibilisatrices  (Rieux  and  Sacquepee). 

This  is  the  reason  why  exact  information  can  be  fur- 
nished by  a  blood-culture  only.  In  the  absence  of  a  blood- 
culture,  in  non-vaccinated  subjects  the  agglutination 
test  should  be  used  for  the  diagnosis  of  typhoid  fever. 

Normally  the  human  blood  serum  does  not  contain 
an  agglutinating  power  higher  than  1  :  10  or  1  :  20. 
This  power  appears  after  anti-typhoid  vaccination 
(1  :  50  to  1  :  10,000). 

In  pathological  conditions  it  often  appears  in  the 
course  of  the  proteiform  manifestations  produced  by 
the  typhoid  bacillus  :  such  as  typhoid  fever,  typhoid 
icterus,  meningo -typhoid,  etc.  Generally  speaking, 
the  reaction  in  typhoid  fever  usually  appears  towards 
the  seventh  day.  Widal  has  sometimes  observed 
it  on  the  third  day.  In  the  course  of  the  disease  the 
curve  of  agglutinating  power  is  infinitely  variable 
and  unforeseen  (Rouget).  It  persists  for  a  varying 
period,  such  as  a  few  months,  or,  more  rarely,  three 
years,  six  years,  or  as  much  as  twenty-six  years  after 
the  disease,  and  sometimes  with  remarkable  intensity 
(I  :  8000  in  a  patient  described  by  Widal  and  Sicard, 
who  had  recovered  from  typhoid  eight  years  previously). 
Its  appearance  may  be  delayed  till  the  second  or  third 


CIRCULATORY  SYSTEM  49 

week;  it  may  appear  only  in  convalescence  or  in  the 
course  of  a  relapse  (Thoinot  and  Cavasse).  Lastly, 
it  may  be  absent  altogether. 

The  serum  may  retain  its  agglutinating  properties 
for  three  or  four  months  after  desiccation.  This  fact 
is  important  to  know  in  view  of  a  retrospective  diagnosis 
or  of  a  medico-legal  report.  The  agglutinating  reaction 
may  pass  from  the  mother  to  the  foetus  (Widal  and 
Sicard),  but  this  passage  is  inconstant  and  incomplete. 

Experimentally,  the  sensibilisatrice  may  be  found  in  a 
young  rabbit  born  of  an  infected  mother  (Vincent  and 
Marbais). 

The  great  variabihty  in  the  appearance  of  the  agglu- 
tinating reaction,  in  spite  of  its  specific  value,  has 
induced  the  chnician  to  seek  in  the  blood  for  the  actual 
cause  of  the  reaction  which  indicates  the  infection. 
This  investigation  is  carried  out  by  a  blood- culture,  with 
which  we  shall  deal  later. 

It  has  been  found  that  the  blood  plasma,  fluid  from 
blisters,  nurse's  milk,  tears,  aqueous  humour,  bile, 
fluid  from  oedema  and  inflammatory  serum  may  possess 
specific  agglutinating  properties  of  varying  intensity 
in  the  course  of  a  typhoid  infection. 

The  toxicity  of  blood  serum  may  be  considerable  in 
the  course  of  the  second  week  of  typhoid  fever,  whereas 
it  is  normal  in  the  first  and  third  weeks. 

The  hcemolytic  power  of  the  blood  is  increased  in 
typhoid  fever.  The  attenuation  of  certain  blood  fer- 
ments is  a  very  grave  symptom,  and  as  a  rule  the 
herald  of  a  rapid  termination  (Achard  and  Clerc). 

The  Pulse  and  Temperature 

The  study  of  the  changes  in  the  pulse  and  the 
temperature  curve  are  not  only  valuable  elements  in 
diagnosis,  but  when  the  diagnosis  is  established  it  is 
by  them  chiefly  that  the  medical  man  can  judge  of  the 
course  of  the  disease,  appreciate  the  patient's  resist- 
ance, establish  an  immediate  or  remote  prognosis  and 
decide  to  intervene  or  abstain  from  treatment.     The 


50    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


pulse  and  temperature  should  be  so  frequently  com- 
pared with  each  other  that,  contrary  to  the  plan  adopted 
in  this  work,  it  appeared  to  us  to  be  of  real  practical 

interest  to 
study  them 
here  side  by 
side.  It  may 
also  be  well  to 
recall  the 
normal  and 
physiological 
characters  of 
the  pulse  and 
temperature, 
so  as  to  illus- 
trate their 
variations  in 
the  course  of 
typhoid  fever. 
Pulse.  — 
Normally,  the 
rate  of  the 
pulse  is,  on  the 
average,  120 
per  minute  in 
an  infant  a 
year  old,  100 
in  a  child  of 
three  years,  80 
in  a  child  of 
8-10  years, 
and  70  in  an 
adult. 

It  becomes 
more  rapid  in 
the  first  weeks 
of  typhoid 
fever ;  it  remains  rapid  at  the  height  of  the  disease,  and 
loses  its  frequency  in  defervescence. 

The    acceleration,    which   is    more    pronounced    in 


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CIRCULATORY  SYSTEM  51 

women  and  children  than  in   the   adult,   varies  con- 
siderably. 

"  Out  of  100  cases,  I  ascertained  that  it  exceeded  the 
normal  standard,  at  some  time  of  the  fever,  in  all  but 
1 ;  in  97  cases  it  exceeded  90  ;  in  85  cases  it  exceeded 
100  ;  in  70  cases  it  exceeded  110;  in  32  cases  it  exceeded 
120;  in  25  cases  it  exceeded  130;  in  10  cases  it  was 
above  140;   and  in  2,  above  150  "  (Murchison). 

The  frequency  of  the  pulse  undergoes  great  variations 
from  one  day  to  another,  and  even  at  different  hours  of 
the  same  day.  In  the  evening  there  may  be  10-30 
beats  more  than  in  the  morning. 

The  pulse  is  accelerated  by  a  pulmonary  complication 
or  an  intestinal  haemorrhage. 

As  a  general  rule,  the  severest  cases  are  those  in  which 
the  pulse  is  most  rapid,  and  usually  it  is  a  bad  prognosis 
when  the  pulse  in  the  adult  keeps  above  120-130  (Fig. 
1).  In  some  cases  the  pulse  may  be  very  slow  (as  low 
as  37  beats  per  minute),  or  never  vary  from  the  normal. 

Irregularities  of  the  pulse  (arrhythmia,  intermittence) 
are  not  rare. 

Characters  of  the  arterial  ivave.  Dicrotism. — At  the 
onset  of  the  disease,  during  the  fu-st  eight  or  ten  days, 
the  pulse  is  strong,  full  and  of  good  tension,  but  soon 
it  becomes  soft  and  compressible.  At  a  more  advanced 
period  it  may  be  small,  feeble,  undulating,  irregular, 
intermittent  or  imperceptible. 

One  of  the  most  remarkable  characters  of  the  typhoid 
pulse  at  the  height  of  the  disease  is  dicrotism.  It  is 
well  known  that  on  sphygmographic  tracings  the  cardiac 
systole  corresponds  not  only  to  the  line  of  ascent  but 
also  to  the  line  of  descent.  The  arterial  pressure,  in 
fact,  increases  until  the  moment  when  the  heart  sus- 
pends its  systolic  effort,  and  the  pressure  falls  only  ^t 
the  moment  when  the  sigmoid  valves  of  the  aorta 
close.  The  impact  of  the  column  of  blood  on  the  valves 
is  indicated  on  the  descending  line  of  the  tracing  by  an 
undulation  which  is  called  "  the  rebound  of  the  pulse," 
or  ''  dicrotism."  Dicrotism,  therefore,  is  a  normal  ele-* 
ment  of  the  pulse,  too  weak  to  be  felt  by  the  finger,  but 


52    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

strong  enough  to  be  registered  on  the  sphygmographic 
tracing.  In  typhoid  fever  this  dicrotism  becomes 
exaggerated  until  it  becomes  perceptible  to  the  finger. 
It  increases  in  proportion  to  the  weakness  of  the  arterial 
pressure  and  the  rapidity  of  the  heart-beat.  Cold  baths 
may  cause  it  to  disappear ;  its  return  may  indicate  a 
threatening  haemorrhage  (Paviot). 

The  arterial  pressure  is  very  low  in  the  typhoid 
patient  (Potain),  but  this  fall  is  only  of  secondary 
importance,  the  changes  in  the  arterial  pressure  being 
related  to  the  frequency  of  the  pulse  (Azelais). 

Temperature. — It  is  well  known  that  in  the  healthy 
man  the  rectal  temperature  varies  at  different  hours  of 
the  day.  On  waking  up  at  six  o'clock  in  the  morning  it 
is,  on  the  average,  98*4°  F.  It  rises  progressively  to  a 
maximum  which  varies  from  99*0°  to  99*5°  at  about 
seven  p.m.,  and  then  sinks  to  a  minimum  of  about 
98-0°  F.  towards  three  or  four  a.m.,  to  rise  later.  We 
may  say  here  that,  normally,  the  excursions  of  the 
temperature  are,  on  the  average,  a  degree  and  a  half. 

The  same  daily  variations  occur  in  tj'^phoid  fever,  but 
the  excursions  are  more  marked. 

In  this  disease  the  morning  temperature  oscillates 
generally  between  103-2°  and  104°  F.,  and  the  evening 
temperature  between  104°  and  105-2°  F.  The  fluctu- 
ation is  from  0*8°  to  2°  F.  But  these  oscillations  may 
be  greater,  and  at  the  height  of  the  disease  be  as  much 
as  3-6°  F.  Lastly,  in  some  cases  the  temperature  tends 
to  return  to  the  normal  level ;  it  rises  again  in  the 
evening,  and  the  great  oscillations  which  result  there- 
from constitute  the  amphibolic  stage  of  Jaccoud. 

Charts  may  also  be  seen  in  which  the  maximum 
temperatures  occur  in  the  morning  and  the  minimum 
in  the  evening.  These  inverse  types  never  appear 
throughout  the  extent  of  the  febrile  cycle. 

Their  significance  is  not  known  apart  from  the  cases 
in  which  the  patient  is  suffering  simultaneously  from 
malaria  or  tuberculosis,  or  has  been  treated  by  anti- 
pyretic drugs. 

But  the  clinical  importance  of  the  cyclical  course  of 


CIRCULATORY  SYSTEM  53 

temperature  is  even  greater  than  its  daily  variations. 
Typhoid  fever  may  be  classed  among  those  diseases 
in  which  the  temperature  curve  usually  pursues  the 
same,  or  almost  the  same,  course.  There  is,  however, 
nothing  absolute  about  it,  for  a  slight  complication  is 
enough  to  modify  the  temperature  curve  and  disguise 
it  effectually. 

Ordinary  Course  of  the  Temperature  in 
Normal  Typhoid  Fever. — In  the  incubation  period, 
in  quite  exceptional  cases,  a  slight  pre-febrile  tempera- 
ture may  be  noted,  usually  in  the  evening,  sometimes 
also  in  the  morning,  reaching  99"  6°  or  100,°  but  never 
exceeding  100*4°  F.  (Vaucher  and  Dufour,  Roch). 

Starting  with  the  truly  clinical  period  of  typhoid 
fever,  the  temperature  curve  may  be  schematically 
compared,  according  to  Jaccoud,  to  the  three  upper 
sides  of  a  trapezium.  The  oblique  ascending  line 
corresponds  to  the  period  of  onset,  or  ascending 
oscillations ;  the  horizontal  line  corresponds  to  the 
height  of  the  disease,  or  stationary  oscillations ;  and  the 
oblique  descending  line  indicates  the  period  of  decline, 
or  descending  oscillations. 

At  the  period  of  onset  (Fig.  4)  the  temperature  rises 
progressively  and  slowly,  exceeding  each  evening,  by  a 
degree  or  more,  the  corresponding  temperature  of  the 
evening  before,  with  a  morning  remission  which  also 
keeps  above  the  record  of  the  previous  morning  by  one 
or  more  degrees. 

These  ascending  oscillations  are  rarely  seen  in  the 
army,  as  the  patients  come  to  the  doctor  too  late. 

In  about  four  days  of  this  staircase-like  ascent  the 
temperature  is  about  103°  F.  It  keeps  at  this  level 
during  the  two  weeks  which  constitute  the  ordinary 
duration  of  the  height  of  the  disease.  During  this 
period  the  morning  remission  varies  from  1°  to  1*8^  F. 
at  most.  The  temperature  curve  may  then  be  com- 
pared to  the  serrations  of  a  saw,  the  base  of  each 
serration  being  102*2°  and  the  point  about  103*0.° 

However,  at  the  onset  of  this  period  of  stationary 
oscillations,  and  especially  about  the  sixth  or  seventh 


54    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


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day,  a  fall  of  tempera- 
ture nearly  to  normal 
is  very  often  seen,  con- 
stituting a  sort  of 
sudden  and  temporary 
remission,  varying  from 
1-8°  to  4-4°,  and  only 
lasting  from  ten  to 
twelve  hours  on  the 
average .  It  is  probabl y 
a  sort  of  thermic  crisis 
which  indicates  a  de- 
fensive state  of  the 
organism,  for  at  this 
moment  the  existence 
of  antibodies  in  the 
blood  may  be  first 
noticed. 

During  the  height  of 
the  disease  the  tem- 
perature shows  a  cer- 
tain stability.  The 
fastigium  of  typhoid 
fever  has  been  called 
by  the  name  of  plateau. 
During  this  period  the 
evening  rise  ranges  be- 
tween 104-2°  and 
104*8°,  the  morning 
temperatures  being,  on 
the  average,  0-8°  to  2- 6° 
lower.  The  height  of 
the  disease,  in  the 
majority  of  cases,  pre- 
sents a  single  plateau, 
but  this  plateau  may 
be  divided  into  two, 
each  lasting  a  week, 
the  second  being  a 
little   above    or  below 


CIRCULATORY  SYSTEM 


55 


the  first.  In  severe  cases  the  temperature  curve  is 
irregular,  capricious  and  steep,  with  temporary  rises 
and  falls  of  grave  prognosis. 

It  is  especially  in  warm  countries  that  such  cases 
are  seen.  Sometimes  the  fastigium  is  prolonged  to  the 
third  or  fourth  week. 

It  is  at  this  period  that  the  amphibolic  stage  of  Jac- 
coud  must  be  placed 
(Fig.  3).  It  is  formed 
by  oscillations  of  great 
amplitude  succeeding 
one  another  without 
any  order  for  three  or 
four  days,  and  giving 
the  curve  a  hesitating 
and  uncertain  char- 
acter, and  followed  by 
frankly  febrile  tempera- 
ture and  actual  hypo- 
thermia. If  the  ter- 
mination is  to  be  fatal, 
the  temperature  rises 
to  107-6°  and  even 
higher  (109-4°),  or,  more 
rarely,  it  falls  consider- 
ably until  death,  which 
takes  place  from  col- 
lapse. 

In  favourable  cases, 
whatever  may  have 
been  the  duration  and 
form  of  the  fastigium, 

defervescence  occurs  in  one  of  two  manners  :  slowly  and 
gradually  by  lysis,  or  suddenly.  Sometimes,  though 
rarely,  a  crisis  is  seen,  characterised  by  very  unusual 
nervous  symptoms  resembling  those  of  meningitis 
(Fig.  5).  In  defervescence  by  lysis  the  curve  is  exactly 
the  reverse  of  that  of  the  ascending  oscillations.  The 
descent  is  made  by  steps  constituting  a  sort  of  "  exit 
staircase  ^'   for   typhoid    fever.     In    cases    of    sudden 


Fig.  5. — Meningeal  symptoms  (deli- 
rium, coma,  strabismus,  etc.) 
towards  the  end  of  typhoid  fever 
on  27th  day.  Sudden  defer- 
vescence. 


56    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


defervescence  this  stage  of  descending  oscillations  may- 
be entirely  suppressed  (Fig.  5).  Very  frequently,  after 
an  apjrrexial  period  of  a  few  days,  a  slight  hypothermia 
(98-0°-98-2°)  may  be  found,  which  is  more  pro- 
nounced in  the  old  and  debilitated,  and  after  long  and 
severe  fevers,  and  may  sink  to  96*8°  and  even  95-8.° 
In  a  few  days  the  temperature  becomes  normal  again. 
Such  is  the  typical  chart  of  the  temperature  in  normal 
typhoid  fever,  which  is  fairly  often  realised.  It  may 
undergo  numerous  variations.     The  onset  is  not  always 

progressive  :  it 
may  be  "brutal," 
the  disease  may 
"explode" 
(Gueneau  de 
Mussy),  and  the 
temperature 
may  in  this  case 
jump  from  98-6° 
to  104°,  imitat- 
ing the  onset  of 
pneumonia. 

It  is  well 
known  that 
paratyphoid 

fevers  frequently  have  a  sudden  onset. 

In  certain  grave  forms  (ataxic  and  ataxo -adynamic) 
the  temperature  curve  is  extremely  irregular.  The 
temperature  of  the  plateau  is  104°  and  above. 

Contrasting  with  these  hypothermic  forms  are  others 
in  which  the  temperature  is  but  little  raised,  and  in 
which  the  plateau  oscillates  between  100*4°  and  101-2°. 
There  are  also  absolutely  apyretic  forms  of  typhoid 
fever  in  which  the  temperature  is  98-6°  or  99-4° 
throughout  the  whole  course  of  the  disease  (H.  Vincent). 
Lastly,  Potain  has  recorded  a  case  of  hypothermic 
typhoid  in  which  the  temperature  fell  from  98- 6°  to 
97-2°,  where  it  remained  until  convalescence,  when  it 
rose  again  to  98- 6°. 

Certain  events  contribute  to  modify  profoundly  the 


Fig.  6.- 


-Hospital  orderly.   Mild  typhoid  fever. 
Defervescence  by  lysis. 


CIRCULATORY  SYSTEM 


57 


regularity  of  the  temperature  curve,  some  causing  a 
rise  and  others  a  fall. 

Complications  which  raise  the  temperature  are 
numerous.  At  the  onset  these  are  the  secondary- 
infections  of  the  pharynx,  and  a  superadded  disease 
(influenza,  diphtheria,  erysipelas,  etc.). 

At  the  height  of  the  disease  they  are  the  pulmonary 
comphcations  (bronchitis,  broncho-pneumonia)  bed- 
sores, suppuration  of  the 
skin,  otitis,  parotitis, 
abscesses,  phlebitis, peri- 
tonitis by  propagation, 
etc.  In  convalescence 
they  are  errors  in  diet, 
fatigue,  lesions  of  the 
bones  or  periosteum, 
constipation,  return  of 
the  menstrual  period  in 
women  (the  last  may 
give  rise  to  false  symp- 
toms of  peritonitis),  etc. 

Among  the  complica- 
tions which  may  cause 
a  fall  of  temperature, 
the  most  important  are 
haemorrhages  (intestinal 
haemorrhage,  profuse  or 
repeated  epistaxis,  de- 
livery or  abortion),  per- 
foration, myocarditis, 
profuse  diarrhoea,  extensive  bedsores,  etc. 

Relations  between  the  Temperature  and  the 
Pulse. — As  a  general  rule,  in  febrile  conditions  if  the 
temperature  rises  a  degree  (r8°  F.),  the  pulse  increases 
by  about  fifteen  beats. 

In  typhoid  fever  a  high  temperature  has  corresponding 
to  it  a  pulse  ivhich  relatively  is  hut  little  accelerated.  A 
change  in  this  formula  in  the  sense  of  acceleration  of 
the  pulse  is  a  grave  sign.  Thus  a  temperature  of  105-8° 
is  not  a  bad  sign  if  the  pulse  is  not  accelerated.     On  the 


Fig.  7. — Man,  aged  59.  Typhoid 
fever  in  course  of  recovery. 
Formation  of  a  renal  abscess 
(staphylococci  and  typhoid 
bacilli).  Spontaneous  opening 
of  the  abscess  on  36th  day. 


58    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

other  hand,  the  prognosis  is  gloomy  if  the  pulse  and 
temperature  rise  simultaneously. 

A  low  t-emperature  and  a  rapid  pulse  should  be  re- 
garded as  a  grave  case.  If  the  temperature  falls  and 
the  pulse  becomes  rapid,  one  should  think  of  the  possi- 
bility of  intestinal  perforation  or  haemorrhage. 

Lastly,  if  in  the  course  of  a  regular  defervescence  by 
lysis  an  increase  in  the  number  of  pulse-beats  is  found, 
the  possibility  of  a  cardiac  complication  should  be 
considered. 


Nervous  System 

Typhoid  fever,  like  all  infectious  diseases,  is  liable 
to  affect  the  nervous  system. 

The  central  anatomical  lesions  which  cause  these 
symptoms,  and  are  due  to  the  toxins  (exo-  and  endo- 
toxins) secreted  by  the  typhoid  bacillus,  are  still  entirely 
unknown  to  us.  Direct  injection  of  the  typhoid  toxin 
into  the  brain  of  a  dog  causes  complete  necrosis  of  the 
nervous  tissue.  But  that  is  a  case  of  a  gross  and 
experimental  lesion. 

The  nervous  symptoms  appear  at  a  variable  period 
of  typhoid  fever.  They  disappear,  become  attenuated 
or  persist  after  recovery.  Sometimes  the  nervous 
manifestations  dominate  the  clinical  picture,  thus 
justifying  the  creation  of  special  forms  such  as  the 
ataxic,  ataxo-adynamic,  delirious,  comatose,  etc. 

In  predisposed  subjects  the  infection  provokes  the 
appearance,  aggravation  or  return  of  latent  nervous 
defects,  which  have  been  attenuated  or  apparently 
cured.  Lastly,  it  acts  as  a  provocative  agent  in 
certain  neuropathies. 

All  these  manifestations  we  must  now  consider  in 
detail. 

Nervous  Symptoms. — These  may  be  classified 
as  follows — 

1.  Symptoms  of  an  ordinary  kind  if  considered 
individually,  but  as  the  result  of  their  special  grouping 


NERVOUS  SYSTEM  59 

in  typhoid  fever,  forming  a  peculiar  syndrome  which 
has  been  given  the  name  of  "  typJioid  state." 

2.  Psychical  disturbances. 

3.  Sensory  troubles. 

4.  Motor  troubles. 

5.  Meningeal  syndromes  (meningitis  and  meningism 
or  meningeal  states). 

6.  Troubles  of  the  organs  of  special  sense. 

1.  Typhoid  State. — The  nervous  symptoms  of  the 
typhoid  state  are  prostration,  stupor,  insomnia,  somno- 
lence, tremors  or  muscular  twitchings,  and  carphology. 

Prostration,  Stupor,  Insomnia,  Somnolence. — Prostra- 
tion exists  in  every  case,  but  in  variable  degrees. 
Sometimes  the  patient  really  seems  like  an  inert  body 
(Louis),  unable  to  move  in  bed  or  attend  to  his  needs. 
Other  patients,  on  the  contrary,  can  sit  up  in  bed, 
get  up  to  go  to  the  closet,  and  even  attend  hospital  for 
advice. 

Prostration  is  sometimes  a  symptom  of  the  onset, 
especially  in  warm  countries,  or  in  soldiers  in  war  time. 
As  a  rule  it  appears  late  in  the  course  of  the  second 
week,  becoming  pronounced  towards  the  end  of  that 
week  or  towards  the  middle  of  the  third  week. 

Sphincter  troubles  are  closely  associated  with 
prostration.  The  stools  and  urine  escape  involuntarily  ; 
retention  of  urine,  necessitating  employment  of  the 
catheter,  is  much  rarer.  During  the  first  eight  or  ten 
days  of  the  disease  the  patient  cannot  sleep,  or  his 
sleep  is  much  disturbed  by  dreams  and  nightmares. 

Somnolence  immediately  follows  insomnia,  at  the 
beginning  of  the  second  week,  but  it  may  be  observed 
from  the  onset.  It  may  be  slight,  moderate  or  deep. 
Sometimes  the  patient  wanders  at  night,  while  in  the 
daytime  he  remains  dull  and  drowsy,  with  his  eyes 
half  closed  and  a  vacant  look ;  he  remains  in  a  somno- 
lent state,  with  intervals  of  delirium.  The  graver 
the  case,  the  earlier,  the  more  intense  and  the  more 
prolonged  is  the  somnolence  (Louis). 

The  typhoid  patient  may  often  have  what  has  been 


60    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

called  the  "  typhoid  facies ;  "  the  face  is  pale,  with  a 
circumscribed  flush  on  one  or  both  cheeks,  the  expres- 
sion is  one  of  prostration  and  stupor,  the  pupils  are 
dilated,  and  the  eyes  sunken.  He  is  incapable  of  any 
rational  act,  and  indifferent  to  persons  and  things, 
but  in  a  varying  degree.  He  has  difficulty  in  putting 
out  his  tongue,  but  once  protruded  he  leaves  it  in  its 
new  position. 

Tremors  and  muscular  twitching s. — Murchison  noted 
tremor  of  the  hands,  tongue  and  lips  in  twenty-seven 
out  of  a  hundred  cases.  He  also  found  subsultus, 
contractions  of  the  mouth  and  hiccough  in  some  cases. 
Children  may  have  choreic  movements. 

In  the  course  of  the  present  war  R.  Mercier  and 
R.  Meunier  found  in  68  per  cent,  of  the  cases  (175 
soldiers)  continuous  tremors,  with  periodic  exacerbations 
characterised  by  rapid  oscillations  (8  per  second)  of 
moderate  amplitude,  with  a  maximum  amplitude  in 
the  acute  stage.  These  tremors  were  independent  of 
the  will,  and  purely  reflex,  and  were  present  at  all 
periods  of  the  disease.  They  were  most  pronounced  in 
soldiers  who  had  undergone  much  fatigue. 

Carpliology. — It  is  not  uncommon  to  find  automatic 
movements  in  typhoid  fever.  Children  constantly 
put  their  hands  to  their  nose  and  bite  their  lips  till 
they  bleed.  Some  patients  push  off  their  bedclothes 
and  try  to  get  up,  or  continually  put  their  hands  on 
their  genitals.  But  the  most  frequent  of  these  auto- 
matic movements  is  that  known  by  the  name  of 
Carj)hology.  The  patient  "  moves  his  hands  to  and 
fro  above  his  bed  and  seems  to  be  groping  for  small 
objects  hanging  in  the  air,  or  to  be  constantly  looking 
for  them  in  his  bedclothes,  from  which  he  pulls  out  the 
nap."  This  continues,  without  interruption,  for  hours. 
Cold-bath  treatment  has  much  reduced  the  frequency 
and  gravity  of  the  stupor  and  other  nervous  phenomena 
accompanying  typhoid  fever. 

2.  Psychical  Disturbances. — Delirium. — Delirium 
is  frequent  in  typhoid  fever,  especially  in  subjects 
who  are  nervous,  depressed,  overworked,  alcoholic,  or 


NERVOUS  SYSTEM  61 

in  a  state  of  exhaustion.  At  the  onset  the  patient's 
sleep  is  broken  and  he  suffers  from  nightmare.  In  the 
daytime  he  gives  himself  up  to  monotonous  reverie. 
At  the  height  of  the  disease  the  delirium  is  at  first 
quiet,  and  presents  the  oneiric  character  peculiar  to 
infective  and  toxic  delirium  (Regis).  It  is  often 
nocturnal.  The  patient  mutters  incoherent  words  in 
a  sort  of  dream,  and  in  the  morning  ends  by  going  to 
sleep. 

The  delirium  afterwards  becomes  diurnal,  and  then 
both  diurnal  and  nocturnal ;  the  prognosis  is  now 
more  serious,  even  if  the  delirium  is  a  peaceful  one. 
But  in  some  cases  it  becomes  violent.  It  is  accompanied 
by  cries  and  disorderly  movements,  and  above  all 
it  becomes  an  active  delirium ;  the  patient  gets  out 
of  bed,  tries  to  escape  and  has  to  be  restrained.  Ac- 
cording to  Regis,  these  are  examples  of  acute  psychosis 
with  terrifying  hallucinations — ideas  of  persecution, 
religious  mania  and  megalomaniac  ideas. 

Subjects  without  any  predisposition  show  an  active 
delirium  with  a  melancholic  state,  or  a  profound  stupor 
with  considerable  mental  excitement.  The  psychosis 
of  the  predisposed  is  a  real  acute  delirium  of  extreme 
gravity,  with  muscular  agitation,  inco -ordination, 
tonic  or  clonic  convulsive  attacks,  and  albuminuria, 
which  may  end  in  collapse.  In  short,  it  is  some  form 
of  mental  confusion,  such  as  hallucinatory  delirium, 
stupor  or  acute  delirium. 

Lastly,  in  the  course  of  every  war  varieties  of 
delirium  have  been  observed  which  Devaux  and  Logre 
have  called  by  the  name  of  "  war  delirium."  Their 
theme  is  essentially  a  military  one,  such  as  dreams 
and  visions  of  fighting,  conversations  and  discussions 
about  strategy,  grim  and  fantastical  stories  of  mas- 
sacres or  deaths  on  the  field  of  honour  followed  by 
resurrections,  scenes  of  the  trenches  or  the  battle- 
field, cries,  restlessness,  the  patient  asking  for  his  gun 
and  wanting  to  fight ;  ideas  of  military  glory,  melan- 
choly ideas  of  guilt,  of  sentence  by  a  court-martial 
and    execution ;     struggles    with    imaginary    enemies, 


62    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Uhlans,  spiked  helmets,  etc.  These  symptoms  of 
mental  confusion  show  how  deeply  the  patients' 
minds  have  been  impressed  by  the  war,  which,  with  its 
picturesque  and  dramatic  features,  forms  almost  the 
only  object  of  their  professional  delirium. 

In  convalescence  some  patients  continue  to  suffer 
from  the  same  psychical  disturbances  as  they  had 
during  the  height  of  the  disease.  When  they  occur 
at  this  time,  and  are  not  due  to  the  administration  of 
caffeine,  these  disturbances  are  due  to  inanition,  and 
disappear  as  soon  as  the  ordinary  diet  is  resumed. 

Typhoid  fever,  however,  may  be  followed  by  the 
appearance  or  return  of  transitory  or  permanent  mental 
disorders,  such  as  mania,  or  chronic  insanity  assuming 
the  hypochondriac,  rehgious,  melancholic,  erotic,  or 
even  ambitious  form.  Mental  degeneration,  various 
forms  of  insanity,  and  general  paralysis  also  occur 
after  typhoid  fever.  As  a  rule,  the  intellectual  and 
affective  faculties  are  weakened,  and  memory  and 
attention  are  considerably  impaired. 

3.  Sensory  Troubles. — The  disturbance  of  general 
sensibility  shows  no  peculiar  features ;  sometimes  one 
finds  cutaneous  anesthesia,  and  sometimes  hyper- 
sesthesia  due  to  neuritis,  especially  in  the  lower  limbs. 

At  the  period  of  onset  the  patient  has  pains  all  over 
the  body,  down  the  spine,  in  the  limbs,  especially  the 
legs,  in  the  epigastrium,  the  nape  of  the  neck,  and  the 
joints.  At  the  height  of  the  disease  the  pain  disappears 
or  improves. 

There  is,  however,  one  symptom  whose  frequency, 
early  appearance  and  duration  entitles  it  to  a  special 
description  :  viz.  headache. 

Headache  is  one  of  the  first  and  most  constant 
symptoms.  It  is.  usually  very  intense  during  the  first 
week,  and  the  patient  attributes  his  insomnia  to  this 
cause.  It  is  usually  frontal,  but  is  sometimes  occipital 
and  may  be  generalised  and  accompanied  by  hyper- 
sesthesia  of  the  scalp.  It  is  generally  a  dull  and 
wearing  pain,  without  any  sharp  or  stabbing  characters. 
In  most  cases  the  patient  is  unable  to  work  or  think ; 


NERVOUS  SYSTEM  63 

noise,  light  and  smell  affect  him  most  disagreeably, 
he  feels  giddy  when  he  changes  his  position  or  sits  up 
in  bed. 

In  moderate  cases  the  headache  lasts  throughout 
the  disease,  in  severer  cases  it  disappears  as  the  patient 
sinks  into  a  condition  of  stupor.  Lastly,  in  some  of 
the  so-called  ambulatory  cases,  headache  is  often  the 
only  symptom. 

Giddiness  disappears  with  the  headache,  but  returns, 
with  or  without  it,  at  the  beginning  of  convalescence. 

4.  Motor  Troubles. — Whereas  the  sensory  dis- 
turbances at  the  period  of  onset  are  specially  localised 
in  the  lower  limbs  and  the  spine,  the  motor  disorders 
are  localised  in  the  upper  limbs,  trunk  and  neck. 
The  patient  has  spasms  and  convulsive  movements, 
such  as  trismus,  strabismus,  hiccough,  etc.  Generalised 
convulsions  are  rarer  than  in  typhus  and  less  frequently 
of  a  ursemic  nature.  Some  patients  have  epileptiform 
attacks,  in  which  they  foam  at  the  mouth  and  bite  the 
tongue,  the  attacks  being  preceded  by  acute  dehrium 
and  followed  by  profound  prostration. 

Aphasia  has  been  observed  in  the  adult,  and  more 
frequently  in  the  child,  during  the  course  of  the  disease 
or  in  convalescence,  but  this  symptom  is  of  short 
duration  and  may  last  only  twenty-four  hours. 

Acute  polioencephalitis  has  been  noted  in  subjects 
under  two  years  of  age.  Its  pathogeny  is  still  obscure. 
The  onset  is  sudden  and  characterised  by  convulsions, 
vomiting  and  fever.  Then  it  is  noticed  that  one  half 
of  the  body  has  become  paralysed.  The  paralysis  is 
most  marked  in  the  arm ;  the  face  is  rarely  affected . 
The  parts  affected  show  maldevelopment,  so  that 
shortening  of  the  arm,  amounting  to  five  or  six  cm., 
may  result  from  the  infection. 

The  reflexes  are  exaggerated ;  contractures  are 
exceptional. 

Sometimes  the  patient  suffers  from  partial  epi- 
lepsy, or,  more  frequently,  hemi -athetosis  with  mental 
disturbance. 

The  typhoid  toxin  is  liable  to  cause  extensive  lesions 


64    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

in  the  cord.  Typhoid  myehtis  may  assume  the  type  of 
acute  ascending  paralysis,  or  Landry's  disease.  In  some 
cases  the  initial  symptoms  are  attributed  to  influenza 
or  gastric  derangement.  In  others  the  myehtis  is 
characterised  by  pains  in  the  trunk  and  hmbs,  anorexia, 
shivering  and,  above  all,  by  fever. 

At  the  height  of  the  disease  enlargement  of  the 
spleen  is  a  guide  to  diagnosis.  Death  is  the  ordinary 
termination  of  the  disease. 

Typhoid  fever  may  be  followed  by  all  the  known 
types  of  paralysis,  as  is  the  rule  after  all  infections. 
But  post-typhoid  paralyses  are  characterised  by  the 
motor  troubles  being  usually  incomplete,  and  being 
accompanied  by  various  sensory  disturbances. 

5.  Meningeal  Syndromes. — Meningitis,  Mening- 
ism  or  "  Meningeal  States.'' — We  will  not  deal  here  with 
the  primary  meningitis,  which  is  one  of  the  forms  of 
typhoid  septicaemia  due  to  localisation  of  the  specific 
bacillus  in  the  meninges.  Nothing  differentiates  it 
clinically  from  acute  cerebro -spinal  meningitis ;  diag- 
nosis can  be  made  only  by  examination  of  the  cerebro- 
spinal fluid. 

The  most  frequent  meningeal  symptoms  in  typhoid 
fever  are  those  observed  at  the  height  of  the  disease, 
from  the  sixth  to  the  twentieth  day,  and  more  rarely 
in  convalescence  or  in  the  course  of  a  relapse. 

The  onset  may  be  sudden  and  violent,  but  is  more 
often  insidious.  Sometimes  all  the  sj^mptoms  of  the 
meningeal  syndrome  are  present,  viz.  headache,  photo- 
phobia, pain  in  the  spine,  vomiting,  contractures,  and 
gun-hammer  position. 

In  children  the  picture  is  frequently  completed  by 
convulsive  attacks  which  may  give  rise  to  a  special 
eclamptic  form.  But  as  a  rule  the  picture  is  incom- 
plete, only  headache  and  rigidity  being  present, 
together  with  Kernig's  sign,  which  is  constantly  found. 

As  isolated  symptoms,  bradycardia,  tachycardia, 
hiccough,  sudden  amaurosis  and  ocular  palsies  have 
been  noted.  Sometimes  there  are  severe  forms  of 
true    typhoid    meningitis    (meningo -typhoid),    with   a 


NERVOUS  SYSTEM  65 

turbid  or  purulent  cerebro -spinal  fluid,  containing  the 
typhoid  bacillus.  Sometimes  the  fluid  is  clear.  The 
disease  should  then  be  regarded  as  an  example  of  the 
meningism  of  Dupre,  and  this  meningeal  state  dis- 
appears spontaneously  or  after  lumbar  puncture. 
Or,  again,  when  there  is  nothing  to  suggest  the  onset 
of  typhoid  fever,  but  there  are  merely  vague  symptoms 
of  a  general  infection,  or  even  no  prodromes  at  all, 
undoubted  signs  of  acute  meningitis  suddenly  appear. 
The  cerebro -spinal  fluid  is  under  hypertension,  clear 
in  colour,  and  does  not  contain  the  typhoid  bacillus, 
which  alone  can  furnish  a  diagnosis. 

It  is  only  the  special  course  of  the  disease  which 
indicates  its  typhoid  origin.  In  a  few  days,  when  the 
meningeal  symptoms  have  disappeared,  the  more 
typical  symptoms  of  typhoid  fever  appear,  viz.  the 
typhoid  facies,  the  caked  tongue,  lenticular  rose  spots, 
etc.  In  exceptional  cases  at  the  onset,  in  the  course 
of  the  disease  or  in  convalescence,  one  may  find  menin- 
gitis produced  by  the  germs  of  secondary  infection, 
either  alone  or  in  association  with  the  typhoid  bacillus, 
such  as  the  staphylococcus  (Sergent  and  Lemaire, 
Giraudet,  Breton),  the  pneumococcus  alone  (Dervitte, 
Sacquepee),  or  associated  with  the  typhoid  bacillus 
(Vincent),  the  tubercle  bacillus  (Chantemesse  and 
Ramond,  Comby),  and  the  streptococcus  (Vaillard  and 
Vincent).  There  is  nothing  to  distinguish  them  from 
suppurative  meningitis.     They  are  always  fatal. 

Special  Senses 

Organ  of  vision. — The  patients  often  complain. of  a 
sensation  of  dazzling ;  often  they  close  their  lids  as  if 
they  had  photophobia.  Jenner  and  Gairdner  have 
noted  a  dilatation  of  the  pupils  which  contrasts  with 
the  contraction  of  the  pupils  seen  in  typhus.  Con- 
tracted pupils  may,  however,  be  found  in  typhoid 
fever  also. 

Keratomalacia  and  necrosis  of  the  cornea  have 
been    noted     (Trousseau),    and     also     phlebitis    with 


66    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

phlegmon    of    the    eye    and    orbit,    irido -choroiditis, 
chorio -retinitis,  etc. 

Organ  of  hearing. — Patients  complain  from  the 
beginning  of  the  disease  of  buzzing  and  ringing  in  the 
ears.  They  may  present  hardness  of  hearing  and  even 
deafness,  which  is  usually  bilateral,  without  lesions  of 
the  ear,  which  suggests  a  central  origin.  Suppurative 
otitis  media  is  not  uncommon,  and  may  cause  in  severe 
cases  absolute  destruction  of  the  tympanum  and  loss 
of  the  ossicles.  Every  degree  of  deafness  may  be 
observed  after  these  attacks  of  otitis. 

Liver  and  Gall  Bladder 

Modern  researches  have  established  experimentally 
the  theory  of  descending  infection  as  opposed  to  the 
theory  of  ascending  infection,  to  explain  infective 
icterus. 

The  initial  phenomenon  is  septicaemia,  which  is 
observed  during  the  incubation  period  before  the 
appearance  of  any  obvious  clinical  sign.  The  in- 
testinal lesion,  which  may  be  absent,  should  be  merely 
regarded  as  one  of  the  localisations  of  the  typhoid 
bacillus,  like  the  other  lesions. 

Experiments  on  animals  and  surgical  operations  on 
the  human  gall-bladder  during  life  have  shown  the 
special  localisation  of  the  typhoid  bacilli  in  the  gall- 
bladder. 

This  localisation  is  usually  accompanied  by  hepatitis 
and  catarrhal  angiocholecystitis,  which  at  their  onset 
have  no  clinical  symptoms.  In  the  course  of  typhoid 
fever  one  may  observe  suppurative  cholecj^stitis,  diffuse 
hepatitis  and  even  hepatic  abscesses  containing  the 
typhoid  bacillus. 

Some  typhoid  infections  resemble  relapsing  jaundice. 
The  infectious  jaundice  merely  indicates  the  localisation 
in  the  liver. 

Mild  primary  infective  jaundice  and  catarrhal  jaundice 
are  the  terms  applied  to  different  degrees  of  the  typhoid 
infection.     Chauffard,   in   particular,   has   contributed 


LIVER  AND  GALL  BLADDER  67 

to  establishing  this  identity  from  a  study  of  epidemics 
of  jaundice  contracted  at  the  same  source,  and  in  wliich 
the  jaundice  maj^  assume  every  clinical  variety,  includ- 
ing evtm  icterus  gravis.  Mild  icterus,  which  appears 
towards  the  third  or  fourth  week,  is  of  transient 
duration,  and  is  accompanied  by  some  tenderness  and 
swelhng  of  the  liver,  the  stools  retaining  their  colour. 

Infective  jaundice  oj  moderate  intensity  i^  accompanied 
by  more  alarming  symptoms. 

"  The  onset  is  usually  sudden ;  the  patient  is  seized 
with  shivering  and  fever,  he  complains  of  pains  in  the 
back  and  lim.bs,  giddiness  and  headache,  which  is 
sometimes  intense ;  digestive  disturbance  is  constant, 
the  tongue  coated,  anorexia  absolute  and  vomxiting 
frequent ;  there  is  a  bilious  diarrhoea  which  is  usually 
profuse,  and  the  temperature  fluctuates  between 
100-4°  and  104°  F. 

"  The  urine  is  scanty,  dark  and  albuminous.  The 
liver  and  spleen  are  often  enlarged  "  (Gilbert  and 
Fournier).  The  jaundice  is  intense,  but  the  stools 
are  not  clay-coloured.  In  a  few  days  improvement 
sets  in  and  the  jaundice  gradually  disappears. 

Lastly,  we  may  meet  with  grave  infective  jaundice, 
which  ends  in  coma  within  a  fev/  days. 

The  typhoid  state  is  intense,  the  jaundice  is  very 
marked  at  the  onset  and  becomes  progressively  less. 
There  are  vomiting,  erythemata,  haemorrhages,  de- 
lirium, mental  confusion,  and  high  temperature  with 
a  more  or  less  pronounced  and  persistent  fall.  "  In 
these  forms  there  is  an  association  of  the  two  anatomo- 
clinical  syndromes,  acute  angiocholitis  and  hepatic 
insufficiency,  but  the  two  syndromes  do  not  run 
parallel  in  their  intensity  "  (Laignel-Lavastine). 

Cholecystitis  is  not  uncommon.  It  may  be  early 
(from  the  eighth  to  the  eighteenth  day)  or  late  (from 
the  twenty-ninth  to  the  fifty-seventh  day,  or  even 
longer  still,  after  defervescence).  In  the  fii^st  case  it 
does  not  in  an}?-  way  affect  the  temperature  curve  ; 
in  the  second  case  a  slight  and  transient  rise  of 
temperature  is  sometimes  noted. 


68    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Jaundice  is  exceptional.  Pain  is  spontaneous  or 
caused  by  pressure  over  the  gall  bladder,  and  is  accom- 
panied by  muscular  resistance  localised  in  the  right 
hypochondrium.  To  investigate  this  sign,  which  is 
present  at  the  onset  and  at  the  height  of  the  disease 
in  every  case  of  typhoid  fever  (Chauffard,  Nobecourt, 
Paisseau  and  Marinier),  the  doctor  should  be  on  the  right 
side  of  the  patient's  bed  and  pass  his  left  hand  back- 
wards along  the  lower  border  of  the  ribs,  so  as  to  make 
the  liver  project  forwards.  The  right  hand  should 
now  depress  the  abdominal  wall  gently  and  progres- 
sively on  to  the  gall  bladder  until  the  patient  com- 
plains of  a  more  or  less  sharp  pain.  This  sign  lasts 
until  the  beginning  of  convalescence.  Its  persistence 
after  the  temperature  has  fallen  should  make  one  fear 
a  relapse  (Radulesco  and  Atanassiu).  In  addition  to 
this  sign  of  tenderness  of  the  gall  bladder,  we  should 
note  the  impaired  resonance  at  the  right  base  which, 
according  to  Lesieur,  is  to  be  found  by  light  percussion 
of  the  right  base  of  the  thorax.  The  upward  enlarge- 
ment of  the  liver  is  responsible  for  this  impaired 
resonance.  It  is  present  in  80  to  90  per  cent,  of  the 
cases  and  occurs  earlier  than  the  rose  spots,  serum 
reaction,  enlargement  of  the  spleen  and  diarrhoea.  It- 
diminishes  and  disappears  in  defervescence.  Its  return 
during  convalescence  indicates  the  onset  of  a  relapse. 

Hepatic  abscesses  in  typhoid  fever  appear  about  the 
fourth  or  fifth  week  and  are  revealed  by  shivering, 
fever,  grave  general  condition,  meteorism  and  pain 
localised  in  the  right  hypochondrium  in  the  region  of 
the  last  costal  cartilages.  The  liver  is  large  and 
painful.  The  disease  may  run  an  acute,  sub-acute 
or  chronic  course",  and  terminates  fatally  when  the 
abscesses  are  multiple,  or  by  opening  into  the  intestine, 
peritoneum  or  lung  when  the  abscess  is  big. 

Peritoneum 

Peritonitis  in  typhoid  fever  may  originate  from 
lesions    of    the    spleen,    liver   and    gall-gladder,    etc., 


LIVER  AND  GALL  BLADDER  69 

but  the  most  frequent  cause  is  perforation  of  the 
intestine. 

We  have  already  studied  intestinal  perforation  and 
the  peritonitis  which  results  therefrom.  Although  it 
has  been  disputed  by  Dieulafoy,  there  is  no  doubt 
that  inflammation  may  be  propagated  by  continuity 
from  the  mucous  to  the  peritoneal  coat  of  the  bowel 
without  any  perforation  (Trousseau).  In  such  cases 
the  starting-point  of  peritonitis  by  propagation  is  to 
be  found  in  a  whitish,  more  or  less  adherent  exudation 
on  the  non-ulcerated  peritoneal  surface,  corresponding 
to  a  Peyer's  patch. 

This  form  of  peritonitis  has  no  special  clinical 
symptoms. 

Urinary  System 

Kidney. — Xephritis  is  fairly  frequent  in  typhoid 
fever.  Murchison  says  that  he  found  it  in  25  per  cent, 
of  his  cases  ;  Griesinger  noted  it  in  a  third  of  his  cases  ; 
Gubler  and  A.  Robin  state  that  it  is  always  present. 
As  a  rule,  the  only  symptom  is  the  presence  of  albumin 
in  the  urine  (at  least,  in  the  mild  or  moderate  cases), 
apart  from  complications.  It  appears  at  dat-es  varying 
from  the  first  week  to  the  middle  of  the  third.  The 
date  of  onset,  amount  and  duration  appear  to  be 
related  to  the  severity  of  the  disease.  As  a  rule,  it 
disappears  in  defervescence,  but  may  persist  and  be 
the  sign  of  a  chronic  renal  lesion. 

Robin  has  described  a  "  renal  form  of  typhoid 
fever  "•  with  the  following  clinical  signs  :  slight  diar- 
rhoea, great  prostration,  adynamia,  earthy  pallor  of 
the  skin,  lumbar  pain,  dyspnoea,  profuse  epistaxis, 
early  cerebral  phenomena,  very  high  temperature, 
mth  great  liabihty  to  chill,  and  extreme  gravity. 
There  is  also  a  primary  acute  hsemorrhagic  nephritis  due 
to  the  typhoid  bacillus,  and  some  forms  of  acute  non- 
hsemorrhagic  nephritis  may  be  due  to  the  same  cause. 

Typhoid  nephritis  is  very  rarely  associated  with 
oedema  and  anasarca. 

Conviilsions  of  ursemic  origin  are  also  rare. 


70     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Bladder. — Relaxation  of  the  sphincters  with  in- 
voluntary emission  of  urine,  and.  retention  necessitating 
the  use  of  a  catheter,  have  been  noted. 

Cases  of  cystitis  manifested  by  pyuria  in  which  the 
typhoid  bacillus  was  present  have  been  reported 
(Vincent,  Levi  and  Lemierre).  A  less  frequent  occur- 
rence is  a  vesical  syndrome  of  mild  degree,  char- 
acterised by  frequent  and  painful  micturition,  a  feeling 
of  weight  in  the  bladder,  tenesmus  and  slight  hsema- 
turia.  These  symptoms  may  disappear  in  a  few  days, 
but  the  pyuria  may  persist,  and  bacteriuria  may  outlast 
pyuria. 

The  urine  in  typhoid  fever. — The  quantity  of  urine 
passed  by  the  typhoid  patient  (1)  diminishes  during 
the  height  of  the  disease ;  (2)  increases  slowly  and 
progressively  during  defervescence ;  (3)  is  abundant 
at  the  onset  of  convalescence.  This  polyuria  has 
received  the  name  of  "  urinary  crisis." 

The  physical  characters,  density  and  reaction  of  the 
urine  vary  with  the  quantity  passed.  At  the  height  of 
the  disease  it  is  the  colour  of  beef- tea  with  green,  red 
or  brown  reflections ,  (Gubler  and  Robin).  Its  specific 
gravity  is  1015—1030  and  more.  It  is  extremely 
acid.  On  defervescence  the  specific  gravity  falls  to 
1017-1019,  and  even  to  1005-1003  at  the  time  of  the 
urinary  crisis. 

The  urine  becomes  paler  and  clearer  as  it  gets  more 
abundant.  Its  acidity  may  diminish  until  it  becomes 
alkaline. 

Urea  increases  during  the  first  week  (28,  57,  62,  78 
grammes  according  to  certain  authors) ;  it  diminishes 
during  the  height  of  the  disease,  but  remains  above 
normal  and  becomes  subnormal  in  convalescence. 

Uric  acid  increases  in  the  febrile  period.  From  the 
normal  0*40  it  may  increase  to  7-30  grammes  on  the 
seventeenth  day  (H.  Jones). 

It  then  decreases  and  falls  below  normal  in  con- 
valescence. The  chlorides  passed  in  the  urine  may  be 
reduced  to  a  mere  trace  (Murchison). 

Laubry  thinks  that  there  are  periods  of  retention, 


LIVER  AND  GALL  BLADDER  71 

alterna/ting  with  small  discharges,  which  precede  the 
abundant  discharge  of  chlorides  in  convalescence. 
According  to  this  writer,  the  chloride  crisis  at  the  end 
of  typhoid  fever  may  occur  in  one  of  three  ways — 

1.  A  sudden  and  complete  discharge  (20  grammes 
per  day  for  several  days). 

2.  An  isolated  and  ephemeral  discharge,  followed  by 
a  very  short  retention  or  by  a  slow  and  progressive 
return  of  the  chlorides  to  normal. 

3.  A  slow  and  continuous  discharge,  which  sometimes 
does  not  occur  till  ordinary  diet  is  resumed. 

The  pJiosphates  and  sulphates  may  be  shghtly 
diminished. 

There  is  no  infection  with  intestinal  lesions  in  which 
so  much  urinary  indican  is  found  as  typhoid  fever. 
Leiicin  and  tyrosin  are  most  likely  to  be  found  in  severe 
cases.     Creatinin  is  never  absent. 

The  urinary  toxicity  is  increased  (Roques  and  Weil). 
From  the  prognostic  point  of  view  the  chloride  crisis 
alone  appears  to  be  of  significance  ;  a  sudden  discharge 
indicates  a  convalescence  with  normal  evolution, 
while  a  slow  discharge  may  indicate  a  relapse. 


Diazo-Reaction 

The  diazo -reaction,  as  a  colour  test  for  the  urine,  has 
long  been  regarded  as  specific  for  typhoid  fever. 

Further  investigations  by  several  authors  have  shown 
that  it  is  present  in  several  febrile  diseases,  e.  g.  measles, 
pneumonia,  scarlet  fever  and  erysipelas.  In  typhoid 
fever  it  appears  from  the  second  to  the  sixth  day,  and 
lasts  till  the  fifteenth  to  the  twentieth  day,  according 
to  the  case,  gradually  losing  its  intensity. 

It  reappears  with  fresh  rises  of  temperature,  and  up 
to  a  certain  point  its  intensity  is  parallel  with  the 
fever. 

The  reaction  has  undergone  certain  modifications. 
The  following  method  is  much  more  deHcate  than  the 
original  one  and  often  gives  immediate  results. 


72     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Reagents. 

1.  Paramidoacetophenol  0  gramme  50 
Concentrated  HCl  50  grammes 
Dissolve  and  add 

Aq.  destill  q.s.  1000  c.m^ 

2.  Sodium  Nitrite  0  gramme  50 
Distilled  water  1000  c.m.^ 

The  urine  to  be  examined  should  have  been  passed 
very  recently,  for  the  reaction  disappears  in  a  few  hours 
after  micturition. 

Pour  10  c.c.  of  solution  (1)  into  a  long  test  tube  and 
mix  with  four  drops  of  the  nitrite  solution  (2),  and 
then  add  10  c.c.  of  urine.  Shake,  make  alkaline  with 
3  c.c.  of  ammonia  and  shake  again  vigorously.  A 
positive  reaction  is  shown  by  the  scarlet  red  colour  of 
the  froth. 

The  Moriz -Weiss  reaction  with  permanganate  of 
potash  has  even  less  value  than  the  diazo -reaction. 


Various  Glands  and  Systems 

Salivary  glands. — The  salivary  secretion  is  usually 
diminished,  sometimes  even  almost  completely  sup- 
pressed. A  few  cases,  however,  of  veritable  sialorrhoea 
are  on  record  (Merklen  and  Milhit). 

Parotitis  may  be  a  sequela  of  adynamic  and  pro- 
longed attacks.  It  is  usually  suppurative,  and  com- 
plicated with  sloughing  and  extensive  sinuses.  The 
prognosis  is  grave. 

The  pancreas  and  thyroid  gland  may  be  the  seat  of 
more  or  less  severe  inflammatory  lesions. 

Testicle. — Patients  aged  from  sixteen  to  thirty,  in 
convalescence  from  an  attack  of  moderate  severity, 
may  suddenly  develop  orchitis,  either  alone  or  in 
association  with  epididymitis,  or  epididymitis  alone. 

The  symptoms  are  those  of  the  orchitis  of  mumps, 
an  effusion  into  the  tunica  vaginalis  being  exceptional. 

The  complication  lasts  about  twelve  days  on  the 


VARIOUS  GLANDS  AND  SYSTEMS  73 

average  (Ollivier),  but  may  be  much  longer.  Suppura- 
tion may  occur. 

The  typhoid  bacillus  has  been  isolated  in  these  cases 
(Vincent). 

Female  genital  organs. — Inflammatory  swelling  of  the 
labia  majora,  ending  in  suppuration,  vulvitis,  Bartho- 
linitis, retro-  or  peri-uterine  hsematocele,  and  a  more 
or  less  severe  gangrene  of  the  vulva  have  been  recorded. 

These  complications  are  rare  and  late  events,  and 
may  pass  unnoticed.  Driout  and  Duplant  saw  an 
ovarian  cyst,  which  had  been  present  for  several  years, 
suppurate  in  the  course  of  typhoid  fever.  The  pus 
was  very  abundant  (10  litres),  and  contained  the 
typhoid  bacillus. 

Lymphatic  glands. — All  the  lymphatic  glands  are 
affected  in  typhoid  fever,  including  the  mesenteric,  or 
extra-mesenteric,  cervical,  lumbar,  inguinal,  bronchial, 
etc. 

The  inflammation  generally  subsides  fairly  quickly. 
It  is  to  its  presence  and  persistence  that  we  may 
attribute  the  paroxysmal  cough,  resembling  pertussis, 
that  may  be  observed  in  convalescence. 

Suprarenal  capsules. — According  to  E.  Sergent  the 
typhoid  state  presents  certain  symptoms,  such  as 
depression,  prostration  and  hypotension,  indicating 
suprarenal  insufficiency,  which  in  an  aggravated  form 
characterises  the  severe  varieties  of  the  disease, 
especially  the  adynamic  and  cardiac  forms. 

Acute  suprarenal  insufflciency  may  be  manifested 
by  a  fall  of  the  temperature  and  arterial  pressure, 
bilious  and  greenish  vomiting,  profound  prostration, 
and  pain  in  the  lumbar  region  which  may  simulate 
peritonitis. 

The  presence  of  suprarenal  insufficiency  may  be 
detected  by  means  of  the  white  line,  and  above  all  by 
the  result  of  treatment. 

If  the  finger  or  a  blunt  object  be  drawn  over  the 
surface  of  the  skin  of  the  abdomen  without  exercising 
any  pressure,  in  thirty  to  sixty  seconds  a  white  line  is 
seen  to  appear,  its  width  being  greater  than  the  blunt 


74    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

object  which  caused  it,  and  lasting  from  two  to  five 
minutes  and  even  more,  and  never  accompanied  on 
each  side  by  a  pink  Hne. 

This  is  Sergent's  suprarenal  white  line,  which  is  the 
converse  of  the  meningeal  red  streak,  and  may  be 
regarded  as  a  reflex  spasm  of  the  capillaries. 

The  suprarenal  origin  of  this  symptom  appears  to 
find  a  definite  proof  in  the  fact  that  adrenalin  admin- 
istered therapeutically  causes  the  hypotension  and 
the  white  hne  to  disappear  simultaneously.  The 
therapeutic  proof  is  without  danger  even  in  the  course 
of  acute  peritonitis,  and  cannot  fail  to  be  of  value  both 
as  a  guide  to  diagnosis  and  as  a  remedy  for  the 
cardio -vascular  asthenia. 

Muscular  System 

The  pathological  anatomy  of  typhoid  myositis  is 
now  well  known,  but  its  clinical  signs  are  still  indefinite. 
We  are  acquainted  only  with  the  lesions  which  result 
from  it,  such  as  muscular  rupture,  haemorrhage  and 
abscesses. 

Muscular  rupture  is  seen  at  the  end  of  the  third  week 
or  in  convalescence. 

It  may  be  the  result  of  a  very  slight  effort  (coughing, 
sneezing,  etc.). 

It  occurs  in  order  of  frequency  in  the  adductors  and 
psoas,  rectus  abdominis  and  pectoralis  minor,  trans- 
versalis,  muscles  of  the  shoulders  and  the  gastrocnemii. 

It  may  pass  unnoticed  or  be  revealed  by  a  sharp 
and  sudden  pain. 

Hcetnorrhage  which  follows  rupture  has  no  symptoms 
if  it  is  deep  and  slight  in  amount ;  if  superficial  it  is 
indicated  by  an  ecchymosis. 

When  it  is  very  profuse  it  may  give  rise  to  a  soft  and 
fluctuating  hsematoma,  with  or  without  an  ecchymosis. 

As  a  rule,  the  rupture  and  haemorrhage  clear  up 
uneventfully,  but  the  lesions  may  suppurate,  as  will 
be  seen  by  local  redness  of  the  skin  and  fluctuation,  as 
well  as  by  a  slight  rise  of  temperature. 


OSSEOUS  SYSTEM  75 

Osseous  System 

The  irritation  of  the  bony  tissue  in  typhoid  fever  is 
revealed  by  exaggerated  groivth  and  the  linem  albicantes, 
due  to  elongation  of  the  skin,  which  are  seen  in  young 
patients  when  they  leave  their  bed.  But  the  most 
interesting  phenomenon  is  the  osteo -periostitis  of  con- 
valescence (Chassaignac  and  Maisonneuve,  Keen),  which 
is  chiefly  met  with  in  those  patients  v/hose  osseous  system 
has  not  yet  attained  its  full  development  (Hutinel). 

It  is  often  multiple  and  symmetrical,  and  may  affect 
any  bone,  but  has  a  predilection  for  the  long  bones, 
especially  the  tibia. 

Hutinel  classifies  the  lesions  of  the  periosteum  as 
follows — 

1.  Circumscribed  periostitis. — This  is  the  most  fre- 
quent form,  but  has  attracted  least  attention  because 
the  symptoms  are  indefinite,  of  short  duration,  and 
complete  recovery  takes  place. 

2.  Osteo-periostitis  ending  in  abscess  formation. — 
Fever,  swelling  of  the  bone  at  a  definite  spot,  and  red- 
ness and  swelling  of  the  skin,  which  gives  passage  to 
pus  from  a  limited  sub-periosteal  abscess,  either 
spontaneously  or  after  incision. 

This  form  always  ends  in  recovery,  but  may  last  a 
very  long  time  owing  to  the  presence  of  sinuses  and 
sequestra. 

3.  Chronic  periostitis  with  gradual  onset,  resulting 
in  deformity  of  the  bone. 

Pysemic  arthritis  may  affect  the  joints,  constituting 
a  primary  localisation  of  the  typhoid  bacillus,  but  no 
special  description  of  the  symptoms  is  needed. 

Polyarticular  arthritis  may  also  occur.  Its  very 
painful  character  and  appearance  at  the  onset  of 
typhoid  fever  may  cause  it  to  be  mistaken  for  acute 
articular  rheumatism. 

Lastly,  monoarticular  arthritis  localised  in  the  knee 
or  hip  is  fairly  frequent  and  is  revealed  by  puffiness, 
swelling  and  pain,  which  end  in  recovery,  ankylosis  or 
spontaneous  dislocation. 


76    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


Skin 

The  skin  of  the  typhoid  patient  is  warm  and  dry. 
In  the  early  hours  of  the  morning  it  becomes  damp 
and  covered  with  perspiration. 

In  defervescence  profuse  sweats  occur  which  have 
been  called  critical.  Forms  of  typhoid  fever  have 
been  observed  in  which  the  perspiration  was  so  profuse 
that  they  were  called  "  sweating  fevers  "  (Borelli, 
Jaccoud).  Perhaps  these  peculiar  forms,  which  are  so 
frequent  in  Southern  Italy,  result  from  an  association 
with  malaria,  or  are  they  really  to  be  regarded  as  due 
to  an  infection  by  the  micrococcus  melitensis  ? 

The  palms  and  soles  present,  a  saffron -yellow  colour 
(Filipowicz),  but  this  is  also  found  in  other  diseases. 
This  palmo-plantar  sign,  as  it  is  called,  may  be  followed 
by  desquamation  of  these  regions  in  convalescence. 

The  desquamation  may  be  more  general  and  extend 
to  all  parts  of  the  body,  especially  in  young  subjects 
(Roger).     The  hair  often  falls  out. 

Eruptions. — Various  eruptions  are  met  with  in 
typhoid  fever.  One  of  them  may  be  regarded  as  a 
specific  clinical  symptom,  viz.  the  lenticular  rose  spots 
of  Louis.     The  others  are  of  secondary  importance. 

According  to  Murchison,  the  lenticidar  rose  spots 
have  a  rose  or  pink  colour,  but  which  varies  slightly 
in  tint  according  to  that  of  the  patient's  skin.  Their 
form  is  rounded  and  regular,  their  margin  is  well- 
defined,  and  they  measure  from  half  a  line  to  two 
lines  in  diameter.  When  the  point  of  the  finger  is 
passed  gently  over  the  skin,  each  spot  can  in  most  cases 
be  felt  to  be  slightly  elevated  above  the  surface.  Their 
outline  is  rounded  or  convex,  but  not  acuminated. 
They  are  never  indurated  ;  but,  in  rare  cases,  a  minute 
vesicle  may  be  discovered  at  their  apex.  They  are 
never  converted  into  petechise ;  but  during  the  whole 
period  of  their  existence  they  disappear  completely  on 
pressure,  and  return  when  the  pressure  is  removed. 

The  seat  of  election  for  the  typhoid  exanthem  is 


SKIN  77 

the  thorax,  abdomen,  axillae  and  sometimes  the  root 
of  the  thighs.  Murchison  often  found  them  on  the 
back,  when  they  were  not  present  anywhere  else,  and 
he  occasionally  noted  that  they  were  larger  and  more 
numerous  on  the  back  than  on  the  front.  The  spots 
are  developed  in  large  numbers  after  a  warm  bath 
(Louis,  Jenner). 

In  most  cases  the  eruption  appears  on  the  seventh 
or  eighth  day.  Exceptionally  it  is  noted  after  the 
twentieth  day  (twentieth  -and  thirtieth  days  accord- 
ing to  Louis,  and  forty-fifth  and  fifty-second  accord- 
ing to  Rilliet  and  Barthez).  After  the  fall  of  the 
temperature  it  is  a  premonitory  symptom  of  a 
relapse. 

An  early  appearance,  before  the  seventh  day,  is  as 
rare  as  a  late  eruption,  and  seems  to  be  an  accompani- 
ment of  severe  and  exceedingly  acute  forms. 

The  eruption  is,  as  a  rule,  discrete.  The  spots  are 
not  very  numerous  at  once ;  they  appear,  without  any 
order,  in  successive  crops,  in  groups  of  three  or  four, 
and  then  disappear  to  give  place  to  others.  The 
average  duration  of  each  spot  is  from  three  to  five 
days. 

The  eruption  lasts  five  to  seventeen  days,  ten  on 
the  average.  There  are  spots,  however,  which  persist 
abnormally  for  ten,  fifteen  and  even  twenty  days, 
and  leave,  on  fading,  a  dark  deposit  of  pigment  or 
copper-coloured  macule.  In  those  cases  in  which 
there  was  a  minute  vesicle  in  the  centre  of  the  spot, 
a  slight  desquamation  occurs  at  the  former  site  of  the 
vesicle.  Certain  spots  are  transient  and  disappear 
in  one  or  two  hours.  As  a  rule,  they  are  not  numerous 
(ten  to  twenty  at  a  time),  and  in  some  cases  they  are 
rarer  still.  It  may  be  possible  to  find  only  three  or 
four,  or  even  less. 

Occasionally  the  eruption  may  be  so  profuse  as  to 
imitate  the  exanthem  of  measles. 

In  subjects  with  a  white  and  fine  skin  the  lenticular 
eruption  is  sometimes  preceded  by  a  hypersemia  which 
sometimes  produces  a  continuous  redness,  and  some- 


78     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

times  a  punctate  rash  limited  to  a  narrow  portion  of 
the  integument.  In  such  cases  it  may  be  mistaken 
for  scarlatina. 

In  severe  forms  the  spot  changes  its  tint  and  grows 
paler  as  the  adynamia  increases.  A  similar  phenomenon 
occurs  at  the  moment  of  death.  Not  only  is  the  erup- 
tion never  to  be  found  on  the  corpse,  but,  in  a  patient 
who  succumbed  when  the  rash  was  fully  developed, 
the  eruption  disappeared  in  a  few  hoars  before  the 
terminal  collapse  (Cheurlot).  The  eruption  is  never 
completely  absent.  In  cases  in  which  no  lenticular 
rose  spots  have  been  found,  they  may  possibly  have 
escaped  notice  for  various  reasons,  e.  g.  small  number, 
transient  duration,  unusual  site,  peculiar  colour  of 
the  skin,  unusually  early  or  late  development,  etc. 

Other  eruptions  may  be  found  in  typhoid  fever,  e.  g. 
purpura,  which  is  always  of  grave  prognosis,  and 
erythemata,  mild  or  severe. 

In  addition  to  the  eruption,  which  may  be  poly- 
morphous, morbilliform  or  scarlatiniform,  the  severe 
cases  are  characterised  by  a  grave  adynamic  general 
condition,  a  fall  of  temperature  with  re-ascent,  vomiting 
of  greenish  fluid,  green  and  foetid  diarrhoea,  and  ulcera- 
tions of  the  lips  and  nose.  The  prognosis  is  grave  (a 
mortality  of  60-80  per  cent.). 

The  well-known  pearly  vesicles  called  sudamina 
are  very  common.  They  are  situated  on  the  front  of 
the  thorax,  on  the  abdomen,  neck  and  axillary  regions. 
They  may  be  more  or  less  confluent,  but,  as  a  rule, 
are  fairly  discrete. 

Gangrene  of  the  slcin  is  fairly  frequent.  It  usually 
occurs  in  those  parts  of  the  body  which  are  for  long 
subjected  to  continuous  pressure.  Examples  are  seen 
in  the  sloughing  of  the  skin  over  the  sacrum  and 
ischium,  elbows,  heels  and  scapulse.  They  are  not  so 
frequent  as  formerly.  They  occur  at  the  end  of  the 
second  week,  or  in  the  third  or  fourth  in  severe  attacks, 
or  in  subjects,  exhausted  by  haemorrhage  or  profuse 
diarrhoea,  who  have  not  received  proper  attention.  They 
may  be  the  starting-point  of  many  more  or  less  severe 


SKIN  79 

complications   such   as   multiple   abscesses,    gangrene, 
erysipelas,  etc. 

In  addition  to  the  serious  typhoid  pycemia,  writers 
have  recorded  cases  of  furunculosis  and  subcutaneous 
abscesses  succeeding  one  another  in  large  numbers  for 
a  long  period  so  as  to  resemble  glanders  (Lailler). 


CHAPTER   III 

CLINICAL    CHARACTERS     OF    PARATYPHOID    FEVERS 

A    AND    B 

In  spite  of  the  similarity  of  their  cHnical  symptoms, 
and  even  of  their  anatomical  lesions,  paratyphoid  fevers 
constitute  morbid  entities  quite  distinct  from  typhoid 
fever.  An  attack  of  typhoid  fever  does  not  confer 
immunity  against  an  attack  of  paratyphoid  fever,  or 
vice  versa.  Since  the  important  investigations  of 
Achard  and  Bensaude  in  1896,  the  clinical  and  bacterio- 
logical history  of  paratyphoid  infection  has  grown 
considerably.  The  paratyphoid  A  and  B  bacilli,  like 
the  typhoid  bacillus,  are  able  to  produce  not  only  general 
infections  of  a  septicsemic  type,  but  also  infections 
which  are  localised  from  the  first.  Belonging  to  the 
same  family  of  bacteria  as  the  typhoid  bacillus,  but 
nevertheless  differing  from  it,  the  paratyphoid  bacilli 
play  a  similar  role  to  the  typhoid  bacilli  in  infections 
of  the  liver  and  bile  ducts.  The  ordinary  clinical 
forms  of  paratyphoid  A  and  B  resemble  those  of  typhoid 
fever,  and  it  is  always  by  comparison  with  the  latter 
that  a  diagnosis  has  hitherto  been  made.  It  was  held 
that  paratyphoid  fevers  in  the  great  majority  of  cases 
assumed  an  attenuated  "  typhoid  "  form. 

Paratyphoid  fevers,  which  had  been  comparatively 
rare  in  France  before  the  present  war,  have  since  become 
very  frequent,  especially  since  August  1915. 

As  accurate  diagnosis  became  more  frequent  by 
discovery  of  the  specific  infective  agent,  it  was  realised 
that  paratyphoid  fevers  had  usurped  their  reputation 
for  benignity,  which  was  perhaps  due  to  a  purely  clinical 
diagnosis. 

80 


CLINICAL  CHARACTERS  OF  PARATYPHOID    81 

At  the  present  time  it  is  agreed  that  paratyphoid 
fevers  A  and  B  may  assume  all  the  symptoms  of 
typhoid  fever  and  reahse  every  chnical  type.  They 
may  even  present  the  same  complications,  which, 
though  possibly  less  frequent  in  paratyphoid  fevers, 
are  equally  severe. ^ 

For  this  reason  it  would  be  difficult  to  give  here  any 
clinical  signs  which  in  themselves  would  be  sufficient 
to  allow  an  exact  diagnosis  to  be  made  between  typhoid 
fever  and  paratyphoid  fevers  A  and  B.  This  diagnosis 
the  laboratory  alone  can  establish  undoubtedly  by 
means  of  an  early  blood-culture. 

The  incubation  period  in  paratyphoid  fevers  varies 
considerably ;  on  the  average  it  is  from  nine  to  fifteen 
days,  but  it  is  sometimes  shorter,  and  may  be  reduced 
to  five  or  six  days  (Sacquepee),  four  to  five  (Dibos),  or 
three  to  eight  (Lenglet). 

The  phenomena  of  onset  resemble  those  of  typhoid 
fever  of  a  mild  form,  viz.  great  lassitude,  insomnia, 
headache,  epistaxis,  nausea,  anorexia,  thirst,  pain  in 
the  back,  orbits  and  nape  of  the  neck,  cramps  in  the 
calves,  etc. 

Shivering  has  been  noted  as  fairly  constant  at  this 
period  (H.  Vincent,  Job,  Robinson),  and  is  sometimes 
repeated  for  several  days.  Constipation  is  very 
frequent  (Sacquepee,  Chevrel),  but  diarrhoea  is  not 
rare  (Meslay  and  Coville,  Job),  being  met  with  in  about 
one  out  of  two  cases  (Lenglet,  Coyon  and  Rivet,  etc.): 
Boidin  and  Burnet  judiciously  remark  that  "  in  the 
course  of  this  war  paratyphoid  fevers  have  often  super- 
vened in  cases  of  prolonged  diarrhoea  which  have  lasted 
three  or  four  weeks  without  fever." 

The  stools  in  paratyphoid  usually  have  a  putrid 
odour  (Job)  and  a  more  or  less  ochre  colour ;  they  con- 
tain greyish  fragments  of  desquamated  and  putrefied 
intestinal  mucosa  (H.  Vincent).     They  do  not  leave  the 

1  It  will  be  remembered  that  the  lesions  found  at  autopsy  may 
be  identical  in  paratyphoid  fevers  and  typhoid  fever.  Ulceration  of 
Peyer's  patches  and  perforative  peritonitis,  however,  are  less 
frequent  in  paratyphoid  fevers  A  and  B. 


82    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

same  coloured  stains  on  the  sheet  and  bed  hnen  as  the 
typhoid  stools  (Landouzy). 

The  onset  of  paratyphoid  fevers  is  often  slow  and 
progressive  (Boidin  and  Burnet,  Coyon  and  Rivet, 
Robinson,  Grenet  and  Fortineau,  Netter  and  Ribadeau- 
Dumas,  etc.).  But,  more  frequently  still,  it  may  be 
sudden,  with  shivering  and  vomiting  which  mark  the 
onset  of  the  infection  (Grenet  and  Fortineau,  Chevrel, 
Job,  Ratherj'',  etc.). 

The  patient  may  then  fix  the  exact  moment  at  which 
he  noticed  the  first  symptom. 

In  three  or  four  days  the  temperature  reaches  its 
maximum,  which  is  about  104°  F.  (Job,  Levi-Valensi, 
Netter  and  Ribadeau-Dumas ,  Chevrel ,  etc . ) .  Vomiting  is 
frequent,  the  patient  may  not  be  able  to  keep  anything 
in  his  stomach.  Severe  headache,  pain  in  the  back, 
and  occipital  pain,  which  may  even  precede  the  febrile 
symptoms,  have  been  noted  as  fairly  common  during 
this  initial  period.  Sometimes  the  onset  may  be 
dramatic  and  simulate  meningitis  (Job,  Netter  and 
Ribadeau-Dumas),  or  appendicitis  (Grenet  and  Forti- 
neau), and  be  accompanied  by  extreme  prostration, 
by  convulsions  in  children,  and  by  vomiting  at  all  ages 
(Job,  Robinson,  etc.).  The  patient  very  soon  begins  to 
resemble  a  case  of  typhoid  fever  of  the  end  of  the  first 
week.  He  preserves  the  congestion  of  the  cheeks  and 
conjunctivae  noted  by  Murchison  as  one  of  the  symp- 
toms of  typhoid  fever.  The  tongue  is  dry  and  coated, 
the  gums  are  covered  with  a  pultaceous  deposit,  and 
the  throat  is  red.  Labial,  facial  and  buccal  herpes 
is  frequently  observed  (Vincent,  Aubry,  Job,-Chevrel)  : 
some  writers,  however,  have  seldom  met  with  it 
(Coyon  and  Rivet).  Sore  throat  is  not  exceptional. 
Duguet's  ulcerations  have  been  found.  At  the  onset 
of  the  disease  the  patient  fairly  often  suffers  from  colic 
and  diffuse  abdominal  pain  on  pressure,  without  special 
localisation  in  the  right  iliac  fossa  (Vincent).  This  pain 
may  last  for  one  or  several  days.  Sometimes  pain 
and  gurgling  have  been  noticed  in  the  right  iliac  fossa 
(Netter  and  Ribadeau-Dumas,  Robinson).     Jacquement 


CLINICAL  CHARACTERS  OF  PARATYPHOID    83 

states  that  "  complete  absence  of  pain  or  tenderness  in 
the  right  ihac  fossa  should  make  one  think  of  para- 
typhoid conditions."  The  abdomen  is  sometimes  dis- 
tended. The  liver  is  almost  always  increased  in  size, 
and  sometimes  to  a  degree  rarely  observed  in  typhoid 
•  fever  (Chevrel).  The  spleen  is  less  big  than  in  typhoid 
fever  (Landouzy),  whereas,  according  to  other  writers, 
it  is  always  much  enlarged  (Job,  Meslay  and  Coville, 
Chevrel),  so  that  its  edge  can  be  felt  several  fingers' 
breadths  below  the  false  ribs  (Aubry). 

Sweating  is  frequent  and  sometimes  profuse,  occur- 
ring late  in  the  evening  or  in  the  night. 

The  lenticular  rose  spots  which  Landouzy  regards  as 
inconstant  are  present  in  60  per  cent,  of  the  cases 
(Robinson).  They  may  be  rare,  or,  on  the  contrary, 
remarkably  plentiful,  appearing  in  successive  crops, 
sometimes  involving  the  face  (Chevrel),  and  extending 
over  the  neck,  cheeks,  arms,  forearms,  and  leaving 
only  a  few  small  areas  of  healthy  skin  (Grenet  and 
Fortineau). 

In  several  cases  a  buccal  enantliem  has  been  found 
(Grenet  and  Fortineau,  Petges,  Dumora  and  Peyri). 
The  rose  spots  sometimes  assume  the  papular  type 
(Meslay  and  Coville),  which  is  rare  in  typhoid  fever. 
They  ma^^  be  large  and  of  short  duration  (Rene 
Benard).  Their  colour  is  sometimes  dark  or  violet 
pink,  with,  occasionally,  a  central  point  in  which  the 
colour  is  more  pronounced  (Lenglet).  They  have 
been  seen  to  appear  after  complete  fall  of  the  tempera- 
ture (Chevrel),  and  to  last  for  several  days  during 
apyrexia  (Vincent). 

The  typhoid  stateis  usually  ill-marked  (Job,  Landouzy, 
Boidin  and  Burnet,  Coyon  and  Rivet,  etc.).  Sorae 
have  found  more  pronounced  nervous  symptoms  than 
in  typhoid  fever,  whereas,  according  to  others,  these 
symptoms  are  either  absent  or  ill-marked  (Etienne, 
Jeandelize  and  Soncourt).  Ataxo-adynamic  forms, 
however,  are  not  exceptional.  Cases  have  been  ob- 
served of  hemiplegia  with  sensory  troubles,  without 
aphasia,  psychosis  of  the  mental  confusion  type  with 


84    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

oneiric  delirium  (Raymond,  Parisot  and  Orticoni), 
psychoses  with  post-oneiric  ideas  (Merklen),  sphincter 
troubles ;  retention  or  incontinence  of  urine,  inconti- 
nence of  faeces  (Merklen),  neuritis  of  the  vagus,  paresis 
of  the  deltoid,  diminution  of  the  reflexes,  ankle  clonus 
and  acute  encephalitis  (Job).  The  urine  is  scanty  and 
dark.  Albuminuria  is  present  in  half  the  cases  (Aubry), 
but  is  slight  and  of  short  durcition  (Job,  Raymond, 
Parisot  and  Orticoni). 

According  to  Aubry,  the  diazo-reaction  is  generally 
absent ;  whereas,  according  to  others,  it  is  fairly  fre- 
quently positive. 

The  pulmoilary  signs  are  very  slight ;  mild  bronchitis 
is  merely  found  in  most  of  the  cases  (Chevrel,  Aubry). 

In  soldiers,  in  the  course  of  this  war,  there  have 
generally  been  found  congestion  of  the  bases,  acute  or 
prolonged  in  character,  congestion  of  the  apex,  simulat- 
ing tuberculosis,  in  which  the  patient  expectorates 
numerous  paratyphoid  bacilli  in  the  sputum,  pleuro- 
pulmonary  congestion,  broncho -pneumonia  (Raymond, 
Parisot  and  Orticoni),  and  pneumonia  with  splenization 
(Minet).  The  hsematological  formula  does  not  differ 
from  that  of  typhoid  fever. 

It  was  generally  thought  that  the  heart  was  rarely 
affected  in  paratyphoid,  and  that  one  could  only  find 
bradycardia  and  extra-cardiac  murmurs,  and  never 
tachycardia.  J.  Minet,  in  19  out  of  60  cases,  observed 
more  or  less  marked  myocardial  manifestations. 

He  found  the  same  clinical  types  as  in  typhoid 
myocarditis — 

(1)  Latent  forms,  most  frequently  met  with,  in  which 
affection  of  the  myocardium  was  revealed  only  by 
examination  of  the  heart  and  pulse. 

(2)  Grave  forms,  in  which  disturbance  of  the  circula- 
tion indicated  the  failure  of  the  cardiac  muscle. 

(3)  Syncopal  forms,  rare,  in  which  sudden  death 
might  be  the  first  and  only  symptom. 

(4)  Chronic  forms,  also  rare,  following  the  acute 
phenomena. 

In  7  out  of  19  cases  this  author  found  tachycardia, 


CLINICAL  CHARACTERS  OF  PARATYPHOID    85 

and  in  11  out  of  19  embryocardia.  In  this  con- 
nection he  remarks  that  foetal  rhythm,  which  is  of 
grave  prognosis  in  the  typhoid  patient,  has  not  the 
same  significance  when  it  appears  as  the  only  cardiac 
sign  in  paratyphoid  fever.  It  assumes  the  character 
of  a  grave  sign  only  when  it  is  accompanied  by  other 
indications  of  cardiac  failure. 

The  temperature  rarely  exceeds  104°  in  the  ordinary 


Jours  de  la  maladif 

10*  11    12    13    14    15   16   17    18    19 

Temper  trt.  S.  m.  s.  m.  s.  m.  s  m.  i   m.  s  m.  s   m.  s.  m.  s  m  s 

9 

7 

S 

f,/\t>3 

**0   /                                                  ^            _^                       

P ^ --•-.. 

'-                          u 

5                                                  P 

inp^                                       \ 

39''/                             1 

5                       4    L 

^        A   «    r  1 

^    ♦     A     A    /    f 

5Qn3     A      /I      /       ^\     \   - 

38   '       f'       I       /     L    /        1        \    K 

^  I    I    I  \    }}    \r 

M  U    J  V   V    1/ 

5  /   y   v    1    1    jt 

^To^i   it^^^tx*^ 

37°i£_f_2 La.fi-S 

9                                                            MlPiJ^ 

'                                           C    ¥    t 

5                                                                        M      ^      ^ 

'irn^ 

36^B--— -  —  --—---  — ------ 

Fig.  8. — Boy,  aged  13-|.     Paratyphoid  fever  A. 

forms.  Its  curve  may  be  exactly  like  that  of  typhoid 
fever  with  a  period  of  ascending  oscillations.  But, 
as  a  rule,  the  fastigium  is  reached  in  two  or  three  days. 
The  height  of  the  disease  is  often  of  very  short  duration. 
In  eight  or  ten  days  (Job),^  or  seven  to  fifteen  (J.  Levy- 
Valensi),  the  temperature  falls  to  normal  by  lysis.  This 
return  may  be  more  rapid  still,  taking  only  two  or  three 
days  (Aubry). 

In  such  cases  the  temperature  curve  does  not  show  a 
plateau.     Sometimes,  however,  the  plateau  is  present, 


86     TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

and  in  severe  cases  may  be  as  high  as  102-2°  or  104*0°, 
sometimes  it  keeps  about  100* 4°. 

Shortened  forms  of  paratyphoid  fever  are  to  be  met 
with,  which  probably  include  a  certain  number  of  the 
cases  which  were  formerly  described  as  febrile  gastric 
derangement,  or  gastric  fever. 

The  pulse  closely  follows  the  temperature.  Its 
maximum  varies,  on  the  average,  from  80  to  100,  or  120. 
As  a  rule,  it  appears  to  undergo  a  marked  slowing  in 
the  period  of  apyrexia,  falling  to  60  beats  in  the  minute, 
and  often  less — 52,  48,  34  (J.  Levy-Valensi). 


Fig.  9. — Girl,  aged  12^.     Paratyphoid  fever  B. 

Generally  speaking,  the  pulse  appears  to  be  slower 
than  in  typhoid  fever  (Robinson).  Dicrotism,  also, 
appears  to  be  rarer. 

The  course  of  paratyphoid  fever  is  shorter  than  that 
of  typhoid,  and,  as  a  rulC;  its  total  duration  is  less  than  a 
fortnight  (Chevrel,  Meslay  and  Coville,  Robinson,  Deve, 
Job).  But,  according  to  certain  authors,  it  may  be  as 
long — three  to  four  weeks,  on  the  average,  rarely  less,  but 
oftsn  longer,  according  to  Aubry,  Coyon  and  Rivet.^ 

1  According  to  Merklen  and  Trotain,  the  duration  of  the  disease 
is  in  relation  to  the  age  of  the  patient:  twenty-four  to  twenty- 
seven  days  for  the  ages  twenty  to  thirty,  and  twenty-seven  to 
thirty-two  days  for  the  ages  thirty-one  to  forty -six. 


CLINICAL  CHARACTERS  OF  PARATYPHOID    87 

Netter  and  Ribadeau-Dumas  have  recorded  cases 
in  which  the  temperature  did  not  become  normal 
until  after  more  than  three  months. 

These  cases  are  not  exceptional.  During  this  long 
period  it  seems,  as  these  writers  say,  that  there  is  a 
succession  of  several  attacks.  These  may  follow  so 
closely  one  upon  the  other  that  there  cannot  be  a 
question  of  relapses;  or,  on  the  other  hand,  several 
days  of  normal  temperature  may  intervene  between  the 
attacks. 

Relapses  are  found  to  be  as  frequent  as  in  typhoid 
fever    (10    per    cent.,    according   to    Rimbaud;    more 


Fig.  10. — Mild  paratyphoid  fever  B.     Positive  blood  culture. 
(Rathery.) 

frequent  still,  according  to  Grenet  and  Fortineau). 
According  to  Job,  recrudescences  are  more  frequent 
than  relapses. 

The  onset  of  convalescence  is  frequently  marked  by 
polyuria. 

The  hypothermic  phenomena  are  rarely  so  marked 
as  those  preceding  the  termination  of  typhoid  fever, 
but  sometimes  the  amphibolic  stage  is  much  more 
pronounced,  especially  in  paratyphoid  A  (Coy on  and 
Rivet).  It  was  for  a  long  time  thought  that  the  course 
of  paratyphoid  fevers  was  mild,  and  that  complications 
were  exceptional.  But  it  has  been  found  that  in  war 
time  these  diseases  fairly  frequently  present  grave  and 
complicated  forms. 


88    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


The  adynamic 
form  is  fairly 
frequent,  especi- 
ally in  para- 
typhoid A  (Boi- 
din  and  Burnet). 
But  an  ataxo  - 
adynamic  form 
of  paratyphoid 
B  has  also  been 
observed. 

Intestinal 
hcemorrhage  is 
not  rare,  being 
accompanied  by 
alarming  symp- 
toms such  as 
fainting  attacks, 
cold  sweats, 
feeble  pulse,  etc. 
It  may  recur  for 
several  days  in 
succession,  or 
reappear  after 
an  interval  of 
a  fortnight  (J. 
Minet).  It  seems 
to  be  less  severe 
than  in  typhoid 
fever,  but  it  may 
be  fatal.  It  is 
observed  in  5  or 
6  per  cent,  of  the 
cases. 

Coyon  and 
Rivet,  in  a  case 
of  paratyphoid 
B  diagnosed  by 
a  blood-culture, 
noted  a  case  of  death  after  twelve  days  of  peritoneal 


CLINICAL  CHARACTERS  OF  PARATYPHOID    89 

symptoms.     It  was  an  instance  of  j^^'^'^^onitis  without 
^perforation. 

Felix  Ramond  and  Schultz  published  a  similar  case, 
which  occurred  on  the  15th  day  of  paratyphoid  A, 
which  had  been  diagnosed  by  a  blood-culture  and 
appeared  to  be  a  mild  case.  The  patient  died  after 
peritoneal  symptoms  lasting  for  seven  days,  a  fall  of 
temperature  to  97*4°,  painful  and  retracted  abdomen, 
diminution  of  the  urine,  and  a  pulse  of  100.  No  blood 
in  the  stools.  Median  laparotomy.  Death  from  car- 
diac collapse.  No  perforation.  Collection  of  pus  in 
the  right  flank.  Bourges  has  observed  intestinal 
'perforation  occurring  insidiously  in  paratyphoid,  and 
without  any  of  the  ordinary  symptoms  of  peritonitis. 
Grenier,  Hornus  in  Morocco,  Raymond,  Parisot  and 
Orticoni  have  also  seen  cases  in  the  course  of  para- 
typhoid A  and  B. 

Raymond,  Parisot  and  Orticoni  have  noted  the 
great  frequency  of  phlebitis.  They  found  seventeen 
cases  in  the  left  lower  limb,  seven  in  the  right  lower  limb, 
and  one  in  the  left  brachial  vein.  Death  occurred  after 
broncho -pneumonia  from  a  suppurative  infarct ;  the 
starting-point  was  a  thrombus  in  the  right  iliac  vein. 
J.  Minet  has  seen  two  cases  of  phlebitis,  one  in  the 
femoral  and  one  in  the  brachial  vein. 

The  kidneys  and  bladder  may  be  severely  affected. 
Cases  of  extremely  abundant  albuminuria  in  para- 
typhoid A,  and  of  hsematuria  in  paratyphoid  B,  have 
been  reported  by  Raymond,  Parisot  and  Orticoni. 

The  respiratory  system  may  be  the  seat  of  grave 
comph  cations. 

Giroux  noted,  in  the  course  of  paratyphoid  A,  a 
pleurisy  which  was  at  first  serous  and  later  purulent 
and  hsemorrhagic.  Pleuro -pulmonary  congestion  of 
protracted  course  is  fairly  frequent,  with  an  effusion 
containing  neutrophil  polymorphonuclears. 

E,  Joltrain  and  G.  Petit  jean  had  the  opportunity  of 
seeing  nineteen  cases  of  pleurisy  among  310  cases  of 
paratyphoid  fever  in  soldiers  (6  per  cent.) ;  eighteen  were 
due  to  the  paratyphoid  B  bacillus,  and  only  one  to  the 


90    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

paratyphoid  A  bacillus.  Fifteen  were  sero -fibrinous, 
two  were  purulent,  and  two  dry.  As  a  rule  they 
appeared  in  the  course  of  latent  or  abortive  forms,  in 
which  they  were  sometimes  the  first  symptoms  (pleuro- 
paratyphoid). 

In  addition  to  the  complications  affecting  the  nervous 
sjT^stem  already  noted,  we  may  mention  a  case  of  typical 
tetany  which  occurred  in  a  patient  on  taking  a  warm 
bath.  In  childhood  he  had  had  repeated  convulsions. 
He  remained  a  subject  of  spasmophilia.  Tetany  was 
present  in  nim  potentially,  and  a  general  disease,  such 
as  typhoid  fever,  was  sufficient  to  render  it  patent 
(Bedos,  Babonneix  and  Corone). 

Parotitis,  simple  or  suppurative,  is  not  extremely 
rare.  Sabrazes  has  published  a  case  of  suppurative 
myositis  of  the  right  pectoralis  major  due  to  the  para- 
typhoid A  bacillus. 

Catarrhal  or  suppurative  otitis  is  fairly  frequent,  as 
well  as  suppurative  lesions  in  the  bones  and  joints. 
Lesions  of  the  liver  and  gall-bladder  (hepatalgia,  hepato- 
megaly and  angiocholecystitis),  certain  very  painful 
forms  of  which  seem  to  give  rise  to  peritoneal  symptoms, 
have  been  noted  in  80  per  cent.,  either  in  the  course  of 
the  disease,  or  after  the  fall  of  the  temperature,  by 
Raymond,  Parisot  and  Orticoni.  Lastly,  the  same 
authors  recorded  a  case  of  orchitis  with  suppuration  in 
the  tunica  vaginalis,  and  Giroux  had  a  case  of  orchi- 
epididymitis with  suppuration  and  elimination  of  the 
afTected  testicle. 

We  can  see  by  the  foregoing  description,  first,  how 
closely  allied  are  paratyphoid  fevers,  by  their  symptoms 
and  complications,  to  true  typhoid  fever ;  and,  secondly, 
how  we  can  only  admit  with  reserve  the  mild  character 
hitherto  attributed  to  the  two  paratyphoid  fevers. 

They  are  certainly  less  frequently  fatal  than  typhoid 
fever.  Statistics,  however,  confirm  their  degree  of 
gravity  during  the  war. 

Merklen  and  Trottain  diagnosed  by  blood-culture 
and  treated  446  paratyphoid  fevers,  356  of  which 
belonged  to  type  A,  and  90  to  type  B. 


CLINICAL  CHARACTERS  OF  PARATYPHOID    91 

They  had  fifteen  deaths,  ten  of  which  occurred  in 
paratyphoid  A  and  five  in  paratyphoid  B.  The  causes 
of  death  were  the  following  :  broncho -pulmonary 
complications,  six  cases ;  intestinal  haemorrhage  and 
perforation,  three  cases ;  virulence  of  infection,  icterus 
and  parotitis,  two  cases ;  cardiac  collapse,  ursemia, 
meningitis,  and  diphtlieria,  one  case  each. 

Grenet  and  Fortineau  diagnosed  by  blood-culture 
seventy-six  cases  of  paratyphoid  A  and  twelve  of  para- 
typhoid B.  They  had  three  deaths,  two  in  paratyphoid 
A  from  intestinal  perforation  and  myocarditis,  and 
one  in  paratyphoid  B  from  intestinal  perforation. 

Deve,  in  201  positive  blood-cultures,  found  140  cases 
of  paratyphoid  A  and  sixty-one  of  paratyphoid  B. 
His  mortality  was  0-7  per  cent,  for  paratyphoid  A  and 
1*6  per  cent,  for  paratyphoid  B. 

These  statistics,  like  those  of  Sacquepee,  Burnet  and 
Weissenbach,  Loger,  Abt  and  Dumont,  Nobecourt  and 
Peyre,  and  J.  Carles,  show  that  in  the  army  in  campaign 
paratyphoid  A  fevers  are  much  more  frequent  than 
paratyphoid  B.  In  certain  regions,  however,  para- 
typhoid B  has  been  predominant.  The  same  statistics, 
as  well  as  those  of  Benard,  Dibos,  etc.,  also  prove  that 
paratyphoid  fever  A  is  less  severe  than  paratyphoid 
fever  B.  Before  the  war  of  1914  paratyphoid  fevers 
were  extremely  rare  in  the  French  army,  in  which 
doubtful  cases  were  examined  by  a  blood-culture. 

As  Prof.  Landouzy  remarks,  complications,  judging 
b}''  the  cases  published,,  seemed  exceptional,  espe- 
cially intestinal  haemorrhage  and  perforation.  But  the 
excessive  predisposition  which  the  war  provoked  for 
diseases  of  typhoid  form,  haemorrhage  and  perfora- 
tion in  the  course  of  this  war  have  become  as  frequent 
as  in  typhoid  fever.  The  first  two  statistics  quoted 
above  further  show  that  out  of  584  authenticated  cases 
of  paratyphoid,  of  wiiich  eighteen  ended  fatally,  five 
deaths  were  due  to  intestinal  kcemorrhage  or  perforation, 
a  mortality  of  0*93  per  cent.,  and  that  these  complica- 
tions were  present  in  more  than  a  quarter  of  the  fatal 
cases. 


92    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Among  170  cases  of  paratyphoid  there  were  eight 
deaths.  J.  Carles  had  two  deaths  from  intestinal 
haemorrhage  and  one  from  perforation,  i.e.  more  than  a 
third  of  the  deaths  were  due  to  these  causes. 

Paratyphoid  fevers,  however,  include  a  number  of 
attenuated  forms  which  may  pass  unnoticed  by  the 
doctor,  or  even  the  patient.  Prof.  Lanclouzy  has  insisted 
on  this  point.  "  Many  morbid  episodes,  hitherto 
described  by  nosographers  as  mild  typhoid,  mucous 
fever,  febrile  gastric  derangement,  are  probably  the 
result  of  infection  by  one  of  the  paratyphoid  bacilli." 
There  are  perhaps  very  few  combatants  who  did  not 
present  these  diminutive  attacks  of  paratyphoid  infec- 
tion, in  the  form  of  colic,  pains  in  the  body  and  limbs, 
and  fever,  for  a  few  days.  It  is  not  less  probable  that 
before  the  period  of  bacteriological  diagnosis  numerous 
pathological  states  described  by  the  name  of  typhoid  fever 
with  sudden  onset,  or  with  abdominal,  pleural  or  hepatic 
complications  were  really  due  to  infection  by  the  para- 
typhoid bacilh  A  and  B. 

The  identity  of  the  symptoms  observed  in  these 
diseases — which  constitute,  nevertheless,  distinct  pro- 
cesses, and  do  not  confer  reciprocal  immunity — easily 
explains  the  confusion.  It  may  be  said  that  with- 
out the  aid  of  the  laboratory  the  exact  diagnosis  of 
typhoid  fever^  or  of  paratyphoid  fever  A  or  B,  cannot  be 
established. 

The  same  statement  applies  to  baciilary  or  amoebic 
d37^sentery,  meningococcal,  parameningococcal  or  pneu- 
mococcal meningitis,  and  to  diphtheria  and  pseudo- 
diphtheria. 

The  infected  organism  cannot,  indeed,  oppose  an 
unlimited  number  of  reactions  to  micro-organisms  which 
are  more  or  less  related  to  one  another,  like  the  typhoid 
and  paratyphoid  bacilli.  Besides  this  more  or  less 
severe  typhoid  form,  with  its  features  which  we  will 
summarise  later,  certain  forms  have  been  .described 
which  are  peculiar  to  paratyphoid. 

The  mild  form,  which  closely  resembles  febrile  gastric 
derangement,   is    characterised    by  digestive    troubles 


CLINICAL  CHARACTERS  OF  PARATYPHOID    93 

such  as  anorexia,  vomiting  and  diarrhoea,  with  a  more 
or  less  intense  febrile  state.  The  onset  is  sudden  and 
the  course  rapid.  Discrete  lenticular  rose  spots  may 
be  seen. 

Some  of  these  infections  which  bear  only  a  distant 
resemblance  to  typhoid  fever,  except  in  the  presence 
of  rose  spots,  are  so  mild  that  it  has  not  seemed  neces- 
sary to  the  patient  to  stay  in  bed.  They  have  received 
the   name   of   "  ambulatory  paratyphoid  "    (Chevrel). 

The  gastro-iniestinal  form,  which  is  usually  due  to 
intoxication  of  alimentary  origin,  presents  variable 
symptoms  according  to  the  gravity  of  the  infection. 
In  these  cases  it  is  the  paratyphoid  B  bacillus  which  is 
the  cause,  or  the  Bacillus  enteritidis,  which  belongs  to 
the  same  group  of  the  Salmonelloses.  The  morpho- 
logical, cultural  and  biological  properties,  as  well  as 
the  pathological  features  of  the  Bacillus  enteritidis 
are  exactly  those  of  the  paratyphoid  bacillus  B,  from 
which  it  can  only  be  separated  by  its  reaction  towards 
agglutinating  serums  (Rieux  and  Sacquepee). 

The  symptoms  due  to  these  alimentary  infections 
generally  begin  shortly  after  the  suspected  meal,  on 
the  average  in  twelve  to  thirty -six  hours,  sometimes 
sooner  and  sometimes  later ;  the  extreme  limits  are 
one  hour  and  four  days.  In  the  same  epidemic  the 
incubation  period  may  vary,  according  to  the  indi- 
vidual, from  one  or  two  hours  to  two  days,  but  as  a  rule 
it  is  the  same  for  all,  so  that  one  may  witness  a  veritable 
explosion,  which  is  often  dramatic  in  its  intensity. 
In  very  mild  cases  the  patient  has  headache  and  diar- 
rhoea, as  well  as  some  pains  in  the  limbs,  presents  more 
or  less  marked  asthenia,  and  sometimes  shows  a  slight 
rise  of  temperature.  Two  or  three  days  afterwards  he 
is  cured.  If  the  attack  is  a  little  more  severe,  the 
preceding  symptoms  are  a  little  more  marked  and 
accompanied  by  colic  and  vomiting.  The  stools  are 
numerous,  liquid,  greenish,  blackish  or  brownish  in 
colour,  and  of  very  foetid  odour.  Vomiting,  which  is 
at  first  alimentary,  becomes  bilious  and  sometimes 
bloody.     The  patient  is  obnubilated,  sometimes  pros- 


94    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

trated.  His  temperature  is  not  high,  as  a  rule,  but  may 
reach  104-8°  (Vagedes).  All  these  symptoms  vary  in 
duration,  lasting  two,  three  or  eight  days,  sometimes 
even  a  month  or  two,  and  even  more. 

Recovery  is  the  rule,  hut  even  in  mild  cases  con- 
valescence is  often  protracted  and  tedious. 

"  When  the  attack  is  still  more  severe  it  almost 
always  assumes  the  appearance  of  cholera  nostras. 
The  stools,  which  are  often  liquid  and  even  of  the  rice- 
water  character,  occur  ten  to  thirty  times  in  the  forty- 
four  hours,  and  are  accompanied  by  persistent  vomiting  ; 
the  small  and  rapid  pulse,  pallor  of  the  face  and  anxiety, 
peripheral  algidity  and  tendency  to  collapse,  prostration 
and  cramps,  remind  one  of  cholera ;  the  temperature 
varies  and  is  fairly  often  below  normal  "  (Sacquepee). 

In  E.  Sergent's  case  the  resemblance  with  cholera 
was  even  more  striking.  After  choleriform  symptoms 
of  the  most  alarming  character  for  three  days  the 
temperature  rose  and  kept  between  103'2  and  103*6°  F. 
for  seven  days.  During  the  course  of  the  intoxica- 
tion the  most  abnormal  symptoms  may  arise,  such 
as  myosis,  conjugate  deviation  of  the  eyes  (Tiberti), 
mydriasis,  aphonia,  incontinence  of  the  anal  sphincter, 
anuria,  purpura  (van  Ermengem),  rose  spots  (Cahn), 
herpes,  etc. 

Icterus  is  exceptional  according  to  Curschmann, 
but  frequent  according  to  Audry,  and  is  shown  by 
pigmentation  of  the  skin  and  urine,  clay-coloured 
stools  and  increase  in  size  of  the  liver  and  spleen. 

Lastly,  some  forms  resemble  dysentery  with  tenes- 
mus, colic  and  very  numerous  bloody  stools  (Jacobson). 

The  choleriform  attacks  usually  run  a  fairly  rapid 
course  lasting  a  few  days,  rarely  more  than  a  week 
(Job,  Audry). 

In  the  course  of  the  same  epidemic  these  different 
forms  may  be  seen  in  existence  simultaneously. 

In  peace  time  the  mortality  is  low.  In  a  total  of 
2725  cases  consisting  of  the  most  different  types 
Sacqu6p6e  found  only  four  deaths — a  mortality  of  1'5 
per  cent. 


CLINICAL  CHARACTERS.  OF  PARATYPHOID    95 

Persons  who  have  had  typhoid  fever  and  who  have 
been  vaccinated  against  it  are  by  no  means  immunised 
against  the  paratyphoid  fevers  A  and  B,  but  may 
contract  paratyphoid  fevers  which  run  an  ordinary 
course. 


CHAPTER   IV 

DIAGNOSIS 

It  is  of  the  utmost  importance  to  make  an  early 
diagnosis  in  typhoid  and  paratyphoid  fevers,  both  in 
the  patient's  interest  so  that  treatment  may  be  com- 
menced as  soon  as  possible,  and  in  the  interest  of  the 
community  so  that  the  necessary  prophylactic  measures 
may  be  taken. 

We  have  already  said  that  by  unaided  clinical  obser- 
vation only  a  presumption  could  be  formed  as  to  the 
existence  of  one  or  other  of  these  affections.  An  exact 
differential  diagnosis  is  only  possible  by  the  help  of 
the  laboratory.  But  this  it  may  be  impossible  to 
obtain.  We  will,  therefore,  devote  the  first  section  of 
this  chapter  to  a  description  of  the  principal  rules  for 
the  clinical  diagnosis  of  typhoid  fever  and  paratyphoid 
fevers. 

In  the  second  section  we  will  study  the  laboratory 
methods,  which  enable  us  to  make  a  diagnosis  by  the 
isolation  and  identification  of  the  causal  agent  of  the 
infection  or  by  the  study  of  the  specific  humoral 
reactions  produced  in  the  organism  by  this  agent. 

I.  Clinical  Diagnosis. 

At  the  onset  the  clinical  symptoms  which  might 
guide  the  diagnosis  are  common  to  all  infections. 
Individually  they  have  only  a  very  relative  value,  but 
collectively  they  gain  in  precision  and  may  make  one  sus- 
pect typhoid  fever.  During  the  first  week  the  diagnosis 
will  be  guided  by  the  malaise,  peculiar  type  of  headache, > 
insomnia,  epistaxis,  slight  iDronchitis,  coated  tongue, 

96 


DIAGNOSIS  97 

or  diarrhoea  with  special  characters,  pain  on  pressure 
in  the  epigastrium,  or  right  iliac  fossa,  with  gurgling, 
and  fever  with  evening  exacerbations  which  become 
more  intense  each  evening. 

If  after  a  week  of  this  state  of  affairs  the  spleen 
becomes  enlarged  and  lenticular  rose  spots  appear, 
there  can  be  no  doubt  about  typhoid  fever,  whatever 
the  other  symptoms  may  be  (Homolle).  A  much  more 
sudden  onset,  with  a  temperature  of  103-2°  F.  on  the 
second  or  third  day,  shivering,  vomiting  and  the 
appearance  of  herpes,  should  make  one  think  rather  of 
paratyphoid  A  or  B.  In  making  a  diagnosis  at  this 
period  one  should  take  into  account  the  existence  of 
an  epidemic,  the  non-acclimatisation  of  the  subject, 
his  age  and  the  life  he  has  been  leading,  as  well  as  his 
pathological  antecedents  (previous  attack  of  typhoid 
or  paratyphoid  fevers). 

At  the  height  of  the  disease  the  gastro -intestinal 
symptoms,  further  increase  in  the  size  of  the  spleen, 
eruption  of  lenticular  rose  spots,  but  most  of  all  the 
typhoid  state,  will  be  the  principal  elements  in  the 
diagnosis.  These  symptoms  and  their  diagnostic 
value  have  been  studied  at  length  in  a  previous  chapter. 

There  is  no  pathognomonic  clinical  feature  in  para- 
typhoid fevers,  either  to  distinguish  paratyphoid  fever 
A  from  paratyphoid  fever  B,  or  to  distinguish  between 
paratyphoid  fevers  and  typhoid  fever  properly  so 
called. 

Paratyphoid  fevers  may  present  all  the  symptoms  and 
all  the  complications  of  typhoid  fever.  However,  one 
may  be  guided  in  the  diagnosis,  though  not  constantly, 
by  certain  .signs,  among  which  the  following  are  the 
most  frequently  observed — 

(1)  The  suddenness  of  the  onset,  with  vomiting  and 
shivering. 

(2)  The  frequency  of  pain  in  the  occiput  at  the 
onset. 

(3)  The  early  eruption  of  labial,  facial  or  buccal 
herpes. 

(4)  An  ill-marked  typhoid  state. 


98    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

(5)  A  fairly  frequent  meningeal  reaction. 

(6)  Slight  degree  of  diarrhoea,  constipation  the  rule. 

(7)  Frequency  and  intensity  of  perspiration  at  the 
onset  or  in  the  course  of  the  disease  (paratyphoid 
fever  A  and  B). 

(8)  The  sometimes  remarkable,  though  not  invariable, 
abundance  of  lenticular  rose  spots,  which  may  appear 
at  the  onset  of  defervescence  and  last  for  some  days 
later. 

(9)  The  frequent  and  considerable  enlargement  of  the 
liver. 

(10)  Shorter  course  of  the  disease. 

We  must,  however,  insist  on  the  fact  that  these 
symptoms  are  not  constant,  that  they  may  exist 
separately,  and  that,  finally,  many  of  them  have  been 
found  in  genuine  typhoid  fever. 

The  only  clinical  character  which  differentiates 
paratyphoid  fevers  is  that  on  the  whole  these  are  less 
severe,  and  accompanied  by  a  lower  mortality  than 
typhoid  fever. 

The  diagnosis  oi  typhoid  fever,  though  easy  in  some 
cases,  may  be  very  difficult  in  others.  The  symptoms 
may  not  be  sufficiently  prominent,  especially  at  the 
onset.  There  may  Ibe  an  absence  or  alteration  of  some 
cardinal  signs  or  a  predominance  of  others  which  are 
of  secondary  importance  in  typical  typhoid  fever. 

At  the  onset  one  may  think  of  influenza  or  the 
eruptive  fevers  in  children,  especially  measles. 

Influenza  generally  has  a  sudden  onset.  The  pro- 
dromal period,  when  present,  is  shorter  than  that  of 
typhoid  fever,  even  with  a  sudden  onset.  The  tempera- 
ture often  rises  suddenly  to  104°  and  even  105-8°  F., 
but  does  not  keep  long  at  this  level.  Sometimes  it 
drops  suddenly  after  two  or  three  days  and  does  not 
rise  again ;  sometimes,  after  a  remarkably  sudden  fall 
lasting  for  twelve  to  twenty -four  hours,  it  rises  as  high 
again  as  before  the  fall,  thus  forming  a  depression  like 
an  upturned  bell  (the  influenzal  V  of  J.  Teissier),  and 
sometimes  it  descends  by  lysis. 

According    to    Jaccoud,    one    may    find    insomnia, 


DIAGNOSIS  99 

epistaxis,  delirium  and  ochre -coloured  diarrhoea  in  the 
intestinal  forms,  and  even  hsemorrhage  from  the 
intestine  ( ?). 

The  patient  may  present  the  typhoid  aspect,  an 
increase  in  size  of  the  spleen,  scarlatiniform  and  mor- 
billiform rashes  and  papular  eruptions  (Van  Swieten, 
Comby,  Perrenot),  sore  throat,  with  redness  of  the 
pharynx  and  swelling  of  the  tonsils. 

But  the  diagnosis  can  be  made  by  the  oculo -nasal 
catarrh,  arthralgia,  neuralgic  character  of  the  head- 
ache, which  is  frequently  supraorbital,  frequent  per- 
spiration, and,  lastly,  the  course  of  the  temperature  and 
absence  of  lenticular  rose  spots. 

The  history  of  an  epidemic  will  be  a  help.  One 
must,  however,  bear  in  mind  a  possible  association 
of  typhoid  fever  and  influenza  (Herard,  Moissenet, 
Potain). 

Eruptive  fevers,  such  as  measles,  smallpox  or  scarla- 
tina, have  a  special  symptomatology  in  the  prodromal 
period  which  will,  as  a  rule,  allow  them  to  be  excluded. 

In  every  case  all  doubt  will  be  removed  by  the 
special  form  of  the  eruption  when  associated  with  a 
history  of  contagion  and  an  epidemic. 

There  are  numerous  diseases  which  borrow  from 
typhoid  fever  its  two  chief  signs  in  the  fully  developed 
stage  (viz.  fever  and  the  typhoid  state),  and  which 
may  cause  errors  in  diagnosis. 

Few  medical  men  in  France  have  seen  typhus  fever, 
which  is  characterised  by  its  sudden  onset,  a  tempera- 
ture of  104°  or  104-8°  F.  on  the  first  day,  with  a  pulse 
between  100  and  120,  constipation  with  an  absence  of 
intestinal  symptoms,  frequent  and  profuse  epistaxis, 
vaso -dilatation  of  the  conjunctivae  (an  important 
symptom),  nasal  mucosa,  and  upper  respiratory  tract, 
and  almost  constant  vomiting  (Bue). 

The  eruption  of  typhus  appears  early,  being  con- 
stituted by  red  or  pink  spots,  which  are  papular  and 
slightly  elevated,  disappearing  at  first  on  pressure,  and 
appearing  first  on  the  abdomen  and  then  invading  the 
whole  body,  except  the  face. 


100    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

After  one  or  two  days  the  eruption  becomes  darker, 
and  the  red  spots  become  transformed  into  petechice, 
which  no  longer  disappear  on  pressure. 

The  delirium  is  very  violent,  with  a  tendency  to 
suicide,  and  at  the  end  of  two  or  three  days  the  patient 
falls  into  a  state  of  extreme  torpor,  with  a  congested 
face.  In  favourable  cases  the  termination  is  sudden. 
Typhoid  fever  is  distinguished  from  typhus  by  its 
slower  onset,  the  later  appearance  of  its  eruption, 
which  is  never  petechial,  by  the  presence  of  intestinal 
symptoms,  and  usually  by  the  less  degree  of  the  typhoid 
state.  1  If  one  also  takes  into  account  the  highly 
contagious  and  dangerous  character  of  typhus,  it  will 
not  be  confounded  with  typhoid  fever.  A  blood-culture 
will  often  aid  in  the  diagnosis. 

In  the  first  rank  of  febrile  infections  of  a  continuous 
type  which  may  simulate  typhoid  fever  are  to  be 
placed  two  forms  of  acute  tuberculosis  :  miliary 
tuberculosis  and  the  typho-tuherculosis  of  Landouzy. 

Acute  miliary  tuberculosis  has  a  less  regular  tempera- 
ture curve,  frequently  showing  great  oscillations  and 
sometimes  assuming  the  inverse  type. 

The  pulse,  which  is  more  rapid  than  in  typhoid 
fever,  is  rarely  dicrotic  and  closely  follows  the  tempera- 
ture. The  pulmonary  signs  are  more  marked  and 
accompanied  with  intense  dyspnoea. 

Photophobia  is  frequent,  the  digestive  symptoms  are 
less  intense,  the  tongue  remains  moist  for  a  long  time, 
being  only  slightly  coated,  the  appetite  fairly  often  is 
only  diminished.  The  abdomen  is  flattened  or  sca- 
phoid, without  any  pain  or  gurgling,  rose  spots  are 
quite  the  exception,  the  typhoid  state  is  much  less 
pronounced,  and  there  may  be  muscular  and  cutaneous 
hypersesthesia. 

1  In  war  time,  however,  the  gravity  of  the  general  signs  of 
typhoid  fever  and  the  symptoms  of  torpor  are  sometimes  so  marked 
that  the  mistake  has  been  made.  The  purpuric  or  hsemorrhagic 
character  of  the  rose  spots  has  also  suggested  typhus.  But  in  such 
cases  cultivation  of  the  blood  during  life,  or  of  the  bile  after  death, 
has  yielded  the  typhoid  bacillus. 


DIAGNOSIS  101 

On  the  other  hand,  the  spleen  may  be  enlarged  as  in 
typhoid  fever. 

The  typho-tuberculosis  of  Landouzy  bears  a  great 
resemblance  to  typhoid  fever,  especially  at  the  onset. 
Its  onset  is  slow  and  progressive,  with  pains  in  the 
limbs,  headache,  epistaxis,  slight  shivering,  abdo- 
minal disturbance,  occasional  vomiting,  constipation  or 
diarrhoea. 

There  are  no  lenticular  rose  spots,  however,  nor 
ochre -coloured  diarrhoea.  The  temperature  shows 
great  oscillations,  which  may  be  as  much  as  2*6  or 
3- 6°  F.  The  dyspnoea  is  very  intense  in  contrast  with 
the  lesions  detected.  A  pleural  localisation  may  occur 
towards  the  third  or  fourth  week.  It  must  not  be 
forgotten  that  typhoid  fever  may  present  the  same 
lesions  or  wake  into  activity  latent  tuberculous  lesions 
of  the  pleura. 

The  infections  due  to  Thiercelin's  enterococcus  are 
usually  mild,  but  may  be  abnormally  protracted  and 
give  rise  to  irregular  pyrexia  with  headache,  thickly- 
coated  tongue,  vomiting,  abdominal  meteorism,  and 
profuse  diarrhoea.  The  spleen  is  somewhat  enlarged. 
There  are  no  rose  spots.  But  typhoid  fever  may  be 
simulated  by  the  duration  of  severe  attacks  of  entero- 
coccal  infection,  which  maj^  last  two  or  three  weeks  or 
more.     Diagnosis  can  be  made  by  a  blood-culture. 

Mediterranean  fever  (melitococcus  infection,  Malta 
fever)  starts  like  typhoid  fever,  and  may  frequently 
be  mistaken  for  it  at  the  onset. 

The  patient  complains  of  headache,  pain  in  the 
limbs,  and  loss  of  appetite ;  the  tongue  is  coated, 
vomiting  is  not  uncommon. 

Furthermore,  a  progressive  rise  of  temperature  with 
a  morning  remission  is  observed.  Pains  in  the  joints 
are  frequent.  Attention  should  be  aroused  by  the 
obstinate  constipation,  and  sweating  at  each  morning 
remission.  The  patient  is  pale  and  asthenic,  and  the 
spleen  is  slightly  enlarged.  Defervescence  occurs  by 
lysis,  and  apyrexia  becomes  complete  in  about  three 
weeks,  but  is  not  permanent.     A  fresh  rise  of  tempera- 


102    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

ture,  similar  to  the  first,  occurs  some  days  later,  then  a 
third,  and  so  on. 

The  disease  generally  ends  by  recovery,  but  may 
last  two  or  three  months,  one  or  two  years,  or  more. 
It  is  characterised  by  the  temperature  curve,  which 
has  given  it  the  name  of  "  Undulant  fever,"  or  "  fever 
with  relapses."  It  is  obvious  that  a  diagnosis  based 
exclusively  on  this  temperature  is  too  late  to  be  of  use. 

Blood-culture  and  Wright's  serum  test  (performed 
with  an  emulsion  of  a  pure  culture  of  the  micrococcus 
melitensis  on  agar)  may  be  carried  out  early  in  the 
disease,  the  specific  agglutinins  appearing  on  the  fifth 
day. 

In  hot  countries,  especially  along  the  Mediterranean 
coast  (Salonica,  Greece,  Turkey,  Syria,  Asia  Minor, 
etc.),  malaria  often  assumes  a  continuous  type,  with 
digestive  disorders,  dry  and  coated  tongue,  bilious 
vomiting,  diarrhoea,  swollen  and  tender  liver,  large 
spleen,  headache,  insomnia,  etc.  The  febrile  state  is 
prolonged  in  patients  who  are  not  treated  with  quinine. 
These  forms  of  so-called  tropical  malaria,  which  are 
sometimes  very  severe,  are  often  confounded  with 
typhoid  and  paratyphoid  fevers.  Their  onset  is 
usually  sudden.  The  temperature  is  irregular  (except 
in  the  remittent  type).  There  are  no  rose  spots.  The 
blood  culture  for  typhoid  and  paratyphoid  bacilli  is 
negative.  Examination  of  the  blood  shows  an  oc- 
casionally considerable  proportion  of  schizontes  and 
gametes.  Lastly  an  energetic  quinine  treatment  (2 
grammes  of  hydrochlorate  of  quinine  daily  or  two 
subcutaneous  injections)  causes  a  rapid  disappearance 
of  the  symptoms. 

It  should  not  be  forgotten  that  typhoid  or  para- 
typhoid fevers  may  be  associated  with  malaria  (typho- 
malarial  fever). 

Acute  articular  rheumatism  may  sometimes  simulate 
typhoid  fever  and  begin  with  sore  throat,  shivering, 
pains  all  over  the  body,  epistaxis  and  fever.  Some- 
times it  assumes  an  ataxic  and  adynamic  form  like 
severe  typhoid  fever.     But  the  patient  sweats  profusely, 


DIAGNOSIS  103 

and  the  localisation  of  the  pain  in  the  joints  soon  forms 
a  guide  to  the  diagnosis. 

Icterus  gravis  begins  with  symptoms  which  simulate 
the  onset  of  typhoid  fever.  After  a  few  days  of 
malaise,  pains  in  the  limbs,  headache,  myalgia,  and 
fever,  or  after  some  vague  gastro -intestinal  disturbance, 
jaundice  develops,  which  may  be  insignificant  or  pro- 
nounced. But  soon  various  haemorrhages  are  observed, 
such  as  epistaxis,  hsematuria,  hsematemesis,  intestinal 
haemorrhage,  purpura,  ecchymosis,  etc.,  accompanied  or 
followed  by  more  or  less  intense  nervous  symptoms, 
such  as  hiccough,  vomiting,  delirium,  convulsions  and 
dyspnoea.  Death  in  coma  may  occur  very  rapidly, 
with  ataxo -adynamic  symptoms  and  a  high  or  sub- 
normal temperature. 

It  must  not  be  forgotten  that  secondary  icterus 
gravis  may  appear  in  tj^phoid  and  paratyphoid  fevers, 
and  that  in  many  cases  icterus  merely  indicates  a 
primary  localisation  of  the  typhoid  or  paratyphoid 
bacillus  in  the  bile  passages\ 

A  typhoid  form  of  infective  endocarditis  has  been 
described,  characterised  by  shivering  from  the  day  of 
onset  and  high  temperature,  with  pulmonary  conges- 
tion, abdominal  distension,  diarrhoea,  enlargement  of 
the  spleen,  and  typhoid  state.  The  diagnosis  may  be 
difficult.  The  cardiac  lesions,  however,  indicated  by 
the  presence  of  murmurs  at  the  orifices,  the  absence 
of  lenticular  rose  spots,  the  course  of  the  symptoms 
when  nothing  is  to  be  found  on  auscultation,  and  the 
development  of  emboli  in  various  situations  accom- 
panied by  shivering  indicating  sepsis,  will  be  a  help  in 
diagnosis,  though  this  can  be  rendered  certain  only  by 
a  blood-culture. 

Apart  from  the  insidious  form  of  pneumonia  which 
appears  at  different  periods  of  typhoid  fever,  and  is 
irregular  in  its  course  and  symptoms  (Dieulafoy),  a 
lobar  pneu77ionia,  on  rare  occasions,  may  mark  the  onset 
of  typhoid  fever.  "  In  the  course  of  the  first  week 
the  symptoms  peculiar  to  pneumonia  subside,  and  are 
followed  by  the  signs  of  typhoid  fever — ^swelling  of  the 


104    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

spleen,  rose  spots  and  iliac  pain  "  (Potain).  In  such 
cases  the  evolution  of  the  disease  will  be  a  guide  to  a 
diagnosis. 

Acute  nephritis  may  have  a  violent  onset,  with  pains 
in  the  loins,  shivering,  high  temperature  and  scanty 
and  dark-coloured  urine. 

One  may  think  of  typhoid  fever,  but  the  rapid  and 
early  appearance  of  the  oedema,  the  pufHness  and  pallor 
of  the  face,  the  intensity  of  the  albuminuria,  and  the 
frequent  haematuria,  will  attract  attention  to  the  renal 
system. 

Pycemia,  septiccemia  and  puerperal  fever  sometimes 
present  a  collection  of  symptoms  which  may  suggest 
typhoid  fever,  such  as  prolonged  pyrexia,  distension 
of  the  abdomen,  diarrhoea  and  typhoid  state.  The 
absence  of  lenticular  rose  spots,  the  oscillations  of  the 
temperature,  shivering  and  profuse  sweats  which 
accompany  these  conditions,  as  well  as  the  character- 
istic local  symptoms  and  the  circumstances  in  which 
they  develop,  will  usually  be  enough  to  distinguish 
them. 

Malignant  hypertoxic  syphilis  may  sometimes  simulate 
typhoid  fever  so  closely  that  Fournier  has  described  it 
by  the  name  of  syphilitic  typhosis.  Numerous  cases 
have  been  published  (Dieulafoy,  Morin,  Courtaux, 
Vialaneix,  Letulle,  etc.).  The  typhoid  phenomena 
usually  appear  during  the  eruption  of  the  secondary 
stage.  The  temperature  reaches  104°,  the  rise  being 
accompanied  by  epistaxis,  vomiting,  headache,  giddi- 
ness, prostration  and  adynamia.  Dyspnoea  and  tachy- 
cardia are  not  uncommon.  Death  from  collapse 
may  occur.  The  diagnosis  will  be  established  by  the 
history  of  syphilitic  infection  and  a  knowledge  of  the 
actual  lesion,  the  absence  of  abdominal  symptoms  or 
enlargement  of  the  spleen,  the  appearance  of  the 
syphilitic  roseola,  negative  blood-culture,  and  Wasser- 
mann's  reaction. 

The  practitioner  is  often  uncertain,  especially  in  the 
case  of  a  child,  as  to  whether  his  patient  is  suffering 
from  tuberculous  meningitis  or  typhoid  fever.     He  is 


DIAGNOSIS  105 

all  the  more  so,  inasmuch  as  "  pyrexia  with  remissions, 
headache,  delirium,  vomiting,  cerebral  maculse,  and 
even  partial  palsy,  inequality  of  pupils,  rolling  the  head 
from  side  to  side,  and  the  hydrocephalic  cry  may  occur 
in  both  diseases  "  (Murchison). 

In  meningitis  vomiting  is  more  frequent,  the  tongue 
is  not  dry,  there  is  no  ochre-coloured  diarrhoea  to  cause 
a  special  stain  on  the  linen,  the  abdomen  is  contracted 
and  not  painful,  the  spleen  is  not  enlarged,  there  is  no 
intestinal  haemorrhage  or  epistaxis,  the  headache  is 
more  intense  than  in  typhoid  fever,  and  is  accompanied 
by  photophobia  and  tenderness  of  the  eyeballs,  and 
sometimes  by  strabismus.  The  trismus,  cutaneous 
and  muscular  hyper sesthesia,  irritability,  gun-hamrner 
position  and  presence  of  Kernig's  sign  will  also  be  in 
favour  of  meningitis.  Lumbar  puncture  and  a  blood- 
culture  will  decide  the  question. 

it  must  not  be  forgotten  that  in  the  course  of  typhoid 
fever  there  may  be  actual  meningitis  and  "  meningeal 
states  "  due  to  the  typhoid  bacillus,  and  that  the 
existencp  of  enteric  fever  does  not  exclude  the  possi- 
bility of  a  concomitant  meningitis  of  tuberculous 
meningococcal  or  other  nature. 

Among  the  other  numerous  diseases  which  may  be 
confounded  with  typhoid  fever,  we  may  mention  the 
typhoid  form  of  lumbricosis  (Chauffard),  acute  osteomye- 
litis, appendicitis  at  the  onset,  cholera  during  the  stage 
of  reaction,  acute  glanders,  acute  trichinosis,  etc.,  etc. 

In  conclusion,  we  will  give  an  account  of  two 
methods  employed  in  the  diagnosis  of  typhoid  fever  : 
Chantemesse's  ophthalmo -reaction  and  Vincent's 
spleno -reaction. 

Chantemesse's  ophthalmo-reaction. — Chantemesse  has 
proposed  Calmette's  method  for  the  diagnosis  of  tuber- 
culosis. A  drop  of  water  containing  Jg-  milligramme  of 
a  powder  obtained  by  precipitation  (with  absolute 
alcohol)  of  a  strong  solution  of  soluble  typhoid  toxin 
is  dropped  into  the  patient's  eye.  The  temperature 
and  general  condition  are  not  affected.  In  persons 
not  suffering  from  typhoid  fever  a  little  redness  and 


106    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

lacrymation  are  observed  in  two  or  three  hours.  In 
typhoid  patients  the  reaction  is  more  pronounced 
(redness,  lacrymation  and  production  of  a  sero- fibrinous 
exudate).  The  reaction  reaches  its  maximum  in  from 
six  to  twelve  hours,  and  continues  till  the  next  day. 
Experiments  have  been  made  with  a  cuti-reaction,  but 
the  results  are  very  uncertain. 

Vincent's  spleno-diagnosis. — Enlargement  of  the  spleen 
being  the  rule  in  typhoid  fever,  it  occurred  to  Vincent 
that  the  inoculation  of  additional  antigen  (2  c.c.  of  a 
concentrated  autolysat  of  living  typhoid  bacilli  steril- 
ised by  ether)  might  result  in  causing  a  splenic  reaction 
which  would  be  useful  for  diagnostic  purposes. 

In  healthy  persons,  or  those  suffering  from  other 
diseases  than  typhoid  fever,  no  splenic  reaction  is 
observed ;  but  in  patients  with  genuine  typhoid  fever 
one  finds,  on  careful  percussion,  an  increase  in  size  of 
the  spleen  by  one  or  two  centimetres  in  both  diameters. 
This  spleno -reaction  is  found,  as  a  rule,  ten  to  eighteen 
hours  after  the  injection,  very  rarely  later. 

It  has  been  observed  in  94  per  cent.,  and  in  35  per 
cent,  it  is  accompanied  by  enlargement  of  the  liver. 

Inoculation  of  an  autolysat  of  paratyphoid  B  bacilli 
in  patients  suffering  from  paratyphoid  fever  B  has 
produced  a  similar  spleno -reaction. 

The  spleen  responds  to  a  specific  irritation  by  an 
equally  specific  enlargement. 

After  injection  of  paratyphoid  B  autolysat  in  the 
course  of  paratyphoid  fever  B,  increase  in  the  size  of 
the  spleen  generally  appears  less  marked  than  after  the 
injection  of  the  typhoid  autolysat  in  typhoid  fever, 
though  it  is  often  very  definite.  Sometimes  this 
increase  in  size  is  more  marked  after  the  second  or 
third  injection  than  after  the  first  (Rathery),  a  circum- 
stance due  to  the  dose  of  antigen  injected. 

The  value  of  the  spleno -reaction  is  that  it  enables 
us  to  make  a  diagnosis  earlier  than  a  blood-culture,  and, 
what  is  still  more  important,  before  the  appearance  of 
clinical  symptoms. 


DIAGNOSIS  107 

II.  Diagnosis  by  Laboratory  Methods 

The  differential  diagnosis  of  typhoid  and  paratyphoid 
fevers  being,  as  we  have  seen,  a  difficult  matter,  it  is 
necessary  to  resort  to  laboratory  examination  as  soon 
as  the  existence  of  one  of  these  diseases  is  suspected. 
The  discovery,  isolation  and  identification  of  the  causal 
agent  are  usually  possible  if  the  investigation  is  made 
under  favourable  conditions. 

Our  study  will  be  divided  into  two  parts,  the  first 
dealing  with  the  methods  of  investigating  the  bacillus, 
and  the  second  with  the  humoral  reactions  of  the 
organism. 

Investigation  of  the  bacillus.  The  typhoid  bacillus 
is  known  to  exist  in  the  Mood  throughout  the  duration 
of  the  infection.  It  persists  through  the  height  of  the 
disease,  and  usually  disappears  at  the  end  of  the  third 
week,  but  it  may  be  found  in  the  blood  even  later. 

After  being  carried  into  the  organism  by  the  circula- 
tion it  may  be  localised  and  multiply  in  any  organ, 
especially  the  spleen,  liver,  bile  passages,  bone  marrow 
and  mesenteric  glands. 

It  is  also  found  in  the  lenticular  rose  spots.  It  is 
present  in  the  intestine  several  days  before  the  appear- 
ance of  the  first  symptoms.  The  number  of  bacilli 
in  the  faeces  increases  until  the  end  of  the  first  week, 
and  gradually  disappears  at  the  end  of  the  fourth. 

The  typhoid  bacillus  fairly  frequently  passes  into 
the  urine  (Bouchard).  Vincent  found  it  in  the  urine 
in  about  a  fifth  of  his  typhoid  cases.  It  sometimes 
persists  in  the  faeces  and  urine  after  recovery,  when  the 
bacilli  are  growing  in  the  gall  bladder  and  bladder. 
According  to  Besson,  the  typhoid  bacillus  is  found 
in  albuminous  urine  exclusively.  It  hardly  ever 
appears  in  the  urine  before  the  tenth  day,  and  as  a 
rule  not  before  the  fifteenth.  In  the  urine  and  faeces 
the  elimination  takes  place  intermittently. 

The  typhoid  bacillus  has  been  found  in  the  pharjmgeal 
ulcers  and  in  the  deposit  on  the  teeth. 

Lastly,  it  has  been  isolated  as  the  causal  organism 


108    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

of  a  large  number  of  complications,  such  as  tonsillitis, 
rhinopharjmgitis,  laryngo -typhoid,  pleurisy,  pneu- 
monia, adenitis,  abscesses,  osteitis,  etc.,  etc. 

As  will  be  seen  from  this  list,  the  infective  agent  may 
be  found  in  every  possible  situation.  Where  should 
the  investigation  be  made  to  obtain  an  invariably 
positive  result  ? 

The  bacillus  can  be  most  frequently  isolated  by 
puncture  of  the  spleen,  but  this  method  is  dangerous, 
as  the  organ  can  easily  be  torn  if  the  patient  makes  a 
sudden  movement. 

Search  for  the  bacillus  in  the  stools  is  a  delicate 
process,  in  which  much  depends  upon  good  luck.  The 
isolation  of  typhoid  or  paratyphoid  bacilli  from  the 
stools  is  often  difficult,  owing  to  the  large  numbers 
of  bacteria  living  in  the  intestine.  This  investigation, 
however,  presents  a  great  prophylactic  and  epidemio- 
logical interest,  being  usually  employed  for  detecting 
germ-carriers  and  determining  how  long  a  convalescent 
may  remain  contagious.  It  is  therefore  advisable  to 
describe  the  usual  methods. 

Plugs  of  mucus  are  sought  for  in  the  stools,  washed 
once  or  twice  in  normal  saline  solution,  and  then 
planted  on  an  appropriate  medium.  According  to  the 
method  advocated  by  Sacquepee  and  Bellot,  the  large 
intestine  is  washed  out  twice  with  a  litre  of  boiled 
water,  it  is  then  washed  out  a  third  time  and  the  last 
part  of  the  evacuated  fluid  is  kept  for  analysis. 

P.  Carnot  and  Weill-Halle  recommend  the  following 
method  :  Fill  one  of  the  branches  of  a  y  tube  of  5-6 
millimetres  in  diameter  with  a  layer  of  fine  sand  up  to 
10  centimetres.  Pour  some  broth  coloured  with 
neutral  red  into  the  other  branch  of  the  tube  until  the 
broth  is  at  the  same  level  in  the  two  branches  a  little 
above  the  sand.  Then  add  to  the  broth  in  the  second 
branch  some  drops  of  the  almost  clear  fluid  obtained 
from  a  second  intestinal  wash-out  following  a  pre- 
liminary evacuant  enema.  Examine  after  eighteen 
hours'  incubation.  The  duration  of  the  stay  in  the 
incubator  is  in  proportion  to  the  height  of  the  layer 


DIAGNOSIS  109 

of  sand  and  the  motility  of  the  bacilli.  The  higher 
the  level  of  the  layer  of  sand,  the  more  accurate  will 
be  the  result  of  the  examination  of  the  micro-organisms. 

The  stay  in  the  incubator  may  be  reduced  to  six 
hours  when  the  height  of  the  sand  is  about  three 
centimetres.  The  broth  above  the  level  of  sand  has 
either  retained  its  colour  but  become  turbid,  or  it  has 
changed  to  a  fluorescent  yellow.  In  the  first  case  the 
typhoid  bacillus  only,  which  is  usually  by  far  the  most 
motile  organism,  has  been  able  to  pass  through  the 
sand  and  grow;  in  the  second  case  the  paratyphoid 
bacilli  A  and  B,  or  the  bacillus  coli,  have  done  so  too. 
A  microscopical  examination  is  made,  before  and  after 
staining  by  Gram's  method.  If  bacilli  are  found  which 
are  not  stained  by  Gram,  they  are  isolated  on  Endo's 
agar  or  Drigalski-Conradi's  medium  in  Petri's  capsules. 
All  the  colonies  stained  red  are  disregarded.  Only 
those  colonies  which  are  unstained,  or  stained  a  very 
faint  pink  or  blue,  are  to  be  examined.  Each  of  these 
will  have  to  be  identified  by  growth  on  special  media, 
and  by  the  examination  of  their  agglutinability. 

It  is  possible  to  isolate  the  bacilli  from  the  lenticular 
rose  spots.  Chauffard  and  J.  Troisier,  by  injecting 
subcutaneously  into  typhoid  patients  -oW^ti  of  the 
dose  of  toxin  fatal  to  a  guinea-pig  weighing  250  grammes, 
succeeded  in  reproducing  a  typical  lenticular  rose  spot 
which  is  generally  identical  with  the  patient's  spon- 
taneous rose  spots.  This  artificial  rose  spot  may  fail 
to  appear  in  some  typhoid  patients  :  its  duration, 
when  it  does  appear,  does  not  exceed  twenty -four  to 
forty -eight  hours.  In  the  typhoid  patient  it  indicates- 
the  presence  of  an  intradermic  colony  of  micro-organ- 
isms. After  washing  the  skin  with  soap,  and  then  with 
alcohol,  prick  the  spot  with  a  needle,  a  small  bistouri 
or  a  vaccinostyle.  Aspirate  with  a  sterile  pipette  the 
drop  of  blood  which  wells  out  through  the  little  opening, 
and  grow  it  in  a  tube  of  bile  broth  and  in  the  water 
of  condensation  obtained  from  agar  tubes. 

By  inclining  these  tubes  the  surface  of  the  agar  is 
moistened  with  the   water  of  condensation,  and  the 


110    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

micro-organisms  are  thus  distributed  all  over  the 
surface  of  the  medium. 

It  has  been  said  that  typhoid  hacteriuria  is  a  late 
event.  Its  investigation  is  only  of  interest  for  prophy- 
laxis and  epidemiology.  The  clot  obtained  aseptically 
by  centrifugalisation  of  the  urine  should  be  planted  on 
Endo's  medium. 

The  pus  obtained  from  various  sources  and  the 
sputum  should  also  be  grown  (I)  in  bile  broth,  (2)  in 
agar  poured  into  Petri's  capsules.  The  organic  media 
in  which  the  typhoid  and  paratyphoid  bacilli  are  to  be 
sought  for  during  life  are  the  blood  and  bile,  and  after 
death  the  heart  blood  and  spleen  pulp. 

Culture  from  the  hile. — Bur,  Hautefeiiille  and  Sevestre 
have  found  typhoid  and  parat3^phoid  bacilli  by  taking 
cultures  from  the  bilious  vomit  which  is  often  seen  in 
typhoid  and  paratyphoid  fevers.  Boldyrev  and  Vol  hard 
have  shown  that  the  introduction  of  a  certain  quantity 
of  oil  into  the  stomach  is  followed  by  a  reflux  of  bile 
mixed  with  pancreatic  juice.  Weber  (in  1909,  in  two 
cases)  and  Kiralyfi  (in  1912,  in  sixty-nine  examinations 
of  thirty  cases)  availed  themselves  of  this  property  for 
the  purpose  of  removing  bile  during  life,  ciiltivating 
it  and  obtaining  posti<ve  results.  After  having  washed 
out  the  stomach  of  a  fasting  patient  with  sterilised 
distilled  water,  250-300  c.c.  of  sterilised  olive  oil  are 
introduced  by  the  same  funnel.  In  half  an  hour's 
time  the  oil  is  withdrawn.  The  patient  must  be  told 
not  to  swallow  his  saliva,  as  it  will  increase  the  number 
of  micro-organisms  in  the  stomach  contents. 

After  the  fluid  has  been  collected  in  a  sterilised  re- 
cipient, it  separates  at  once  into  two  layers,  the  upper 
formed  by  the  oil  and  the  lower  containing  the  bile. 
Carnot  and  Weill -Halle  administer  only  50-150  grammes 
of  olive  oil,  which  they  remove  by  gastric  intubation 
three  hours  later. 

In  the  exceptional  cases  where  gastric  mucus  only  is 
withdrawn,  it  should  be  cultivated,  for  the  typhoid 
bacillus  may  be  found  in  it  fairly  often,  although  less 
constantly  than  in  the  bile. 


DIAGNOSIS  111 

Carnot  and  Weill -Halle  also  perform  direct  intubation 
of  the  duodenum  by  making  the  patient  swallow  a 
rubber  tube  of  about  three  millimetres  in  diameter  and 
one  metre  long,  terminated  by  a  little  glass  nozzle,  open 
at  the  two  ends,  which  has  been  carefully  sterilised  and  is 
protected  by  the  rubber  tube  up  to  its  terminal  orifice. 
The  patient  swallows  eighty  centimetres  of  the  tube, 
which  is  left  in  position  for  three  hours,  sometimes  four, 
by  which  time  the  nozzle  has  passed  through  the 
pylorus  and  penetrated  into  the  duodenum.  Aspira- 
tion is  then  made  with  a  syringe  fitted  to  the  outer  end 
of  the  rubber  tube.  If  the  nozzle  is  in  the  right  position, 
almost  pure  bile  is  withdrawn. 

The  writers  themselves  admit  that  this  technique  is 
not  always  easy  to  carry  out  "  in  some  typhoid  patients 
in  a  state  of  prostration,  who  are  incapable  of  executing 
intelligently  the  measures  required." 

These  two  processes,  however,  give  almost  the  same 
results. 

Carnot  and  Weill -Halle  regard  cultivation  of  the  bile 
as  a  measure  possessing  great  prophylactic  importance. 
In  most  cases  it  yields  results  later  than  blood-culture. 
It  cannot  be  carried  out  before  the  end  of  the  first  week, 
but  it  enables  us  to  trace  a  carrier  long  after  the  disease 
has  come  to  an  end.  Thus  the  writers  found  the 
typhoid  bacillus  in  the  bile  after  the  sixth  month. 

Blood-culture. — Very  numerous  methods  have  been 
employed.  It  would  be  tedious  and  unnecessary  to 
describe  them  all.  As  the  blood  serum  possesses 
strongly  bactericidal  properties,  some  recommend  that 
a  fairly  large  quantity  of  blood  should  be  grown  on  a 
very  large  quantity  of  a  fluid-culture  medium.  The 
blood  is  taken  by  aseptic  puncture  of  a  vein  at  the  fold 
of  the  elbow.  Ten  to  twenty  c.c.  are  collected  and 
put  in  a  litre  of  beef  broth,  or,  more  economically, 
following  H.  Lemierre's  example,  in  ordinary  peptone 
solution  prepared  as  follows — 

Peptone 20  grammes 

Sodium  chloride  ....  5  „ 

Water 1000 


112    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

This  process,  which  has  been  copied  from  Castellani 
and  Busquet,  has  been  employed  for  several  years  by 
J.  Sabrazes,  who  prefers  it  to  others  as  being  the  most 
simple,  practical  and  certain  method.  Lafforgue 
separates  the  corpuscles  from  the  plasma  after  adding  to 
the  blood  a  2  per  cent,  solution  of  citrate  of  soda  (1  drop 
per  c.c.  of  blood),  centrifugalises  it  and  pours  the  clot 
into  broth-tubes. 

In  the  course  of  this  war  bacteriologists  have  en- 
deavoured to  discover  the  most  favourable  culture 
medium,  and  one  which  does  not  require  elaborate 
apparatus. 

Bile  has  been  chiefly  in  favour,  either  in  a  pure  state 
after  sterilisation,  or  associated  with  beef  broth, 
Liebig's  extract,  or  peptone  solution.  The  media  with 
a  bile  base  possess  the  great  advantage  of  avoiding  the 
coagulation  of  blood  and  of  forming  an  excellent  soil 
for  the  cultivation  of  typhoid  and  paratyphoid  bacilli. 

Filtered  bile,  diluted  to  a  third  or  half  of  its  volume 
by  broth  or  peptone  solution,  appears  best. 

P.  Carnot  and  Weill -Halle  have  also  employed  U 
tubes  with  a  sand  filter  two  centimetres  high  for 
blood-culture.  Into  one  of  the  branches  of  the  tube 
they  put  the  mixture  of  sterilised  ox  bile  (five  c.c.)  and 
the  patient's  blood  (twenty  to  thirty  drops),  and  into 
the  other  a  sterile  broth.  The  motile  bacilli  growing 
in  the  bile  pass  through  the  layer  of  sand  and  multiply 
in  the  broth,  where  they  can  be  much  more  easily 
examined  on  the  following  day. 

Muratet,  in  his  field  laboratory,  has  availed  himself 
of  this  process,  which  has  been  of  great  service  to  him, 
with  the  following  slight  modifications. 

The  tubes  are  larger  than  those  of  Carnot  and  Weill - 
Halle.  Two  to  three  c.c.  of  blood  are  grown  in  one  of 
the  branches  of  the  U  tube  containing  five  c.c.  of  ox 
bile  and  five  c.c.  of  peptone  solution.  Into  the  other 
branch  is  poured  broth  coloured  with  neutral  red 
(Savage's  medium).  When  the  blood-culture  is  posi- 
tive. Savage's  broth  may  become  turbid  without  losing 
its  red  colour,  or  it  assumes  a  fluorescent  yellow  colour. 


DIAGNOSIS  113 

P.  Carnot  and  Weill-Halle  describe  a  still  simpler  pro- 
cess, which  consists  in  making  a  culture  of  pure  bile  and 
then  introducing  a  layer  of  broth  above  the  bile -blood 
medium,  taking  care  to  avoid  a  mixture.  The  culture 
may  be  made  in  an  ordinary  test  tube  which  presents 
a  certain  advantage,  for  the  manufacture  of  U  tubes  is 
not  always  easy  in  the  army  on  active  service,  and  these 
tubes  often  break  in  the  course  of  sterilisation  or 
manipulation. 

When  fresh  ox  bile  is  not  available,  dried  bile,  or  the 
"  ox  gall,"  to  be  obtained  from  a  chemist's,  may  be 
dissolved  in  peptone  solution.  This  method  gives 
good  results,  and  one  can  always  have  a  small  store  of 
bile  extract  in  the  laboratory. 

The  substitution  of  bile  salts  for  bile  does  not  consti- 
tute a  more  favourable  medium  (Sabrazes). 

Whatever  the  method  employed,  one  proceeds  as 
follows  with  the  examination  of  the  cultures  and  the 
identification  of  the  organisms. 

The  first  microscopical  examination  may  be  made  with 
a  slide  and  coverslip  or  with  a  hanging  drop-culture, 
without  staining,  to  see  if  the  bacilli,  whether  motile 
or  non-motile,  have  grown.  In  positive  cases,  if  the 
bacilli  are  motile  and  are  not  stained  by  Gram,  we  may 
be  dealing  with  one  of  the  micro-organisms  of  the  coli- 
typhoid  group. 

As  regards  these  cultural  reactions,  generally  speak- 
ing the  paratyphoid  A  bacillus  resembles  the  typhoid 
bacillus,  and  the  paratyphoid  B  bacillus  the  bacillus  coli. 
Paratyphoid  bacilli  are  motile,  do  not  stain  by  Gram, 
possess 8-10  flagella  and  are  facultative  anaerobes.  They 
cause  fermentation  in  glucose,  mannite,  dulcite,  Isevul- 
ose,  maltose  and  galactose,  but  not  in  lactose,  raffinose 
or  cane  sugar.  They  differ,  therefore,  from  the  typhoid 
bacillus,  which  does  not  ferment  any  sugar.  They  do 
not  coagulate  milk  or  produce  indol,  which  differentiates 
them  from  the  bacillus  coli,  which  ferments  all  sugars. 
One  should  bear  in  mind  the  existence  of  infections 
due  to  the  B.  fcecalis  alcaligenes  and  the  properties 
of  this  micro-organism,  which,  though  very  like  the 


114    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


o 
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to 

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less    so    than    ty- 
phoid   bacillus. 
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lotting  of  milk,  red 
coloration     in    24 
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DIAGNOSIS 


115 


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Decoloration,    fluor- 
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Growth    on   lactose, 
raffinose     or     sac- 
charose media. 

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g 

116    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

typhoid  bacillus,  nevertheless  turns  litmus  milk  strongly 
alkaline. 

The  identification  of  the  organisms  isolated  must  be 
completed  by  a  study  of  their  agglutindbility  by  means  of 
specific  experimental  serums.  The  serums  employed 
for  this  purpose  must  be  of  moderate  strength,  1  per 
1000  to  1  per  10,000.  They  have  sometimes  a  marked 
agglutinating  property  for  other  species  (coaggiutina- 
tion).  The  largest  possible  number  of  typhoid  bacilli 
are  agglutinated  in  the  same  degree  hy  the  same 
experimental  serum. 

Some  bacilli,  however,  which  have  been  recently 
isolated  from  the  blood,  fseces  or  water,  are  not  agglu- 
tinable,  although  they  possess  all  the  characters  of  the 
typhoid  bacillus.  Before  regarding  them  as  genuine 
typhoid  baciJli,  they  must  undergo  several  passages 
through  broth.  By  this  process  the  genuine  typhoid 
bacillus  progressively  acquires  a  considerable  agglutinat- 
ing power. 

It  seems  that  there  is  some  parallelism  between  the 
lack  of  agglutinative  power  and  the  absence  of  motility 
(C.  Nicolle  and  Trenel).  The  experimental  serums  are 
specific  for  the  typhoid  and  paratyphoid  bacilli.  They 
agglutinate  all  the  strains  in  almost  the  same  dilution. 
Exception  must  be  made  for  the  paratyphoid  B  bacilli, 
of  which  the  different  strains  are  agglutinated  in  very 
unequal  dilutions. 

As  the  experimental  serums  contain  amboceptors, 
the  reaction  of  fixation  of  the  complement  can  be 
applied  for  the  diagnosis. 

However,  if  this  amboceptor  is  specific  for  the 
typhoid  bacillus,  this  is  not  the  case  with  the  paratyphoid 
bacilli  A  and  B. 

Experimental  serums  deviate  the  complement  in  the 
presence  of  the  paratyphoid  bacilli  with  which  they 
have  been  obtained,  but  the  experimental  serum  ob- 
tained with  the  paratyphoid  A  bacillus  contains  an 
amboceptor,  which  acts  equally  on  the  typhoid  bacillus 
and  the  paratyphoid  B  bacillus. 

In  like   manner,  the  experimental  serum  obtained 


DIAGNOSIS  117 

with  the  paratyphoid  B  bacillus  contains  an  ambo- 
ceptor which  also  acts  on  the  typhoid  bacillus  (Rieux 
and  Sacquepee). 

We  cannot  close  this  chapter,  which  is  necessarily 
very  incomplete,  without  reminding  our  readers  that 
in  diseases  resembling  typhoid  fever  pathogenic  micro- 
organisms, differing  from  the  typhoid  and  paratyphoid 
bacilli  by  one  or  more  characters  reputed  to  be  specific, 
have  been  isolated  during  life  by  means  of  blood-culture. 

They  may  be  described  as  "intermediate  bacilli'" 
to  indicate  that  they  belong  to  a  group  which  possesses 
some  of  the  characters  of  the  typhoid  and  paratyphoid 
bacilli,  without  any  suggestion  that  they  represent  a 
stage  of  passage  from  one  micro-organism  to  the  other. 
Cases  of  this  kind  have  been  published  by  Moutier, 
Faroy,  Lecount  and  Kirby,  LafPorgue,  etc.  A  certain 
number  of  cases  has  also  been  published  in  which  the 
clinical  symptoms  were  like  those  of  typhoid  or  paratyphoid 
fever,  but  in  which  B.  fcecalis  alkaligenes  was  isolated 
by  blood -culture. 

This  micro-organism  undoubtedly  possesses  patho- 
genic properties  for  man,  giving  rise  to  infections  which 
are  sometimes  mild  and  sometimes  remarkably  severe, 
especially  in  Morocco.  The  symptoms,  and  even  the 
character  of  the  autopsy  lesions,  may  resemble  those 
of  typhoid  fever.  The  study  of  this  micro-organism 
should  be  carefully  pursued. 

Lastly,  there  has  been  found  in  the  patients'  blood, 
in  addition  to  the  typhoid  or  paratyphoid  bacilli,  a 
certain  numbei"  of  pathogenic  micro-organisms,  such  as 
the  micrococcus  melitensis  (Basseres,  Rauzier  and 
Roger,  Laggrifoul,  Arnal  and  Roger),  proteus  vulgaris 
(Vincent),  staphylococcus,  streptococcus  (Vincent), 
bacillus  pj^ocyaneus  (Vincent),  haemamoeba  malarise 
(Kelsch  and  Kiener,  Vincent),  etc.,  etc. 

Sometimes  one  of  the  paratyphoid  bacilli,  especially 
B,  may  be  found  at  the  same  time  as  the  typhoid  bacillus 
(C.  Gautier  and  R.  J.  Weissenbach). 

The  presence  of  these  micro-organisms  gives  a  special 
character  to  the  typhoid  infection,  completely  modifies 


118    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

its  characters,  and  sometimes  considerably  increases  its 
gravity. 

III.  Study  of  the  more  or  less  Specific  Humoral 

Reactions  caused  in  the  Organism  by 

Typhoid  Infections 

Widal's  serum  test. — In  a  previous  chapter  we  indi- 
cated the  principle  of  this  test.  We  must  now  discuss 
in  detail  some  special  points. 

Normally  human  serum  agglutinates  the  typhoid 
bacillus  at  1  in  10-1  in  20,  and  the  paratyphoid  bacilli  at 
1  in  50,  even  at  1  in  150  (Sacquepee,  Chevrel,  Beco).  In 
the  course  of  typhoid  or  paratyphoid  infections  human 
serum  acquires  agglutinating  properties.  But  these 
properties  may  be  absent.  They  generally  appear 
towards  the  end  of  the  first  week,  and,  on  the  average, 
acquire  their  maximum  from  the  twelfth  to  the  twentieth 
day.  Besides  the  blood  serum,  nurse's  milk  (Achard 
and  Bensaude),  urine,  tears,  pleural  fluid  and  cerebro- 
spinal fluid  (Brandeis  and  Mongour)  may  be  endowed 
with  agglutinating  power.  The  mother  can  transmit 
it  to  the  foetus. 

This  agglutinating  power  is  not  absolutely  specific. 
Side  by  side  with  agglutinins  there  exist  group  co- 
agglutinins. 

Thus  the  serum  of  patients  suffering  from  typhoid 
fever  may  agglutinate  paratyphoid  A  and  B  bacilli 
as  much  as,  and  even  more  than,  the  typhoid  bacillus 
(Sacquepee).  Likewise,  the  serum  of  patients  suffering 
from  paratyphoid  A  infection  agglutinates  paratyphoid 
A  bacilli  in  low  dilution  (1  in  100  or  1  in  200),  but  it 
may  agglutinate  the  typhoid  bacillus  and  paratyphoid 
B  bacillus  in  the  same  dilution.  The  serum  of  patients 
with  paratyphoid  B  infection  can  agglutinate  very 
energetically  the  patient's  own  bacillus  (even  up  to 
1  in  40,000),  but  much  less  other  bacilli  of  the  B  type 
(1  in  100-1  in  1000).  It  is  much  less  active,  as  regards 
the  typhoid  bacillus  and  paratyphoid  A  baccillus.  An 
attempt  has  been  made  to  get  rid  of  these  coagglutinins 


DIAGNOSIS  119 

by  Castellani's  process.  But  this  test,  which  is  accurate 
in  the  case  of  e;xperimental  serums,  is  much  less  reliable 
in  the  case  of  human  serums,  and  its  clinical  value  is 
doubtful  (Rieux  and  Sacquepee.)  To  make  use  of  the 
reaction  it  has  been  necessary  to  standardise,  so  to 
speak,  the  agglutinating  power  of  the  serum  for  the 
typhoid  bacillus  and  paratyphoid  bacilli  A  and  B. 
Dilutions  had  to  be  pushed  to  extreme  limits,  and  only 
strong  dilutions  were  taken  into  account.  Paradoxical 
agglutinations,  nevertheless,  will  still  be  met  with. 
Some  writers,  however,  state  that  one  can  make  a 
diagnosis  of  typhoid  infection  if  human  serum  agglutin- 
ates the  typhoid  bacillus  at  a  minimum  dilution  of 
1  in  150-1  in  200,  and  in  a  much  lesser  degree  the 
paratyphoid  bacilli  (M.  Labbe,  Cade  and  Vaucher). 
According  to  Salomon,  in  the  presence  of  a  negative 
blood-culture  recourse  should  be  made  to  the  serum 
test,  even  in  the  inoculated.  One  may  "  regard  as  of 
value  agglutinations  for  paratyphoid  A  and  B  occurring 
at  a  minimum  dilution  of  1  in  200,  but  importance 
should  only  be  attached  to  agglutinations  of  the 
typhoid  bacillus  when  they  are  definite  and  intense  in 
dilutions  of,  or  exceeding,  1  in  500." 

In  cases  where  a  serum  agglutinates  a  paratyphoid 
bacillus  more  than  a  typhoid  bacillus,  "  nothing  allov/s 
us  at  present  to  conclude  that  we  are  in  presence  of 
a  paratyphoid  infection "  (Sacquepee  and  Chevrel). 
According  to  Rist,  the  specificity  of  the  serum  reaction 
is  still  less  certain.  "  The  serum  reaction  is  of  no  value 
as  a  guide  as  to  whether  the  typhoid  bacillus  or  para- 
typhoid A  or  paratyphoid  B  bacillus  is  the  cause  of  the 
disease.  Blood-culture  alone  enables  us  to  differentiate 
them.  A  positive  serum  agglutination  in  the  non- 
inoculated  fully  authorises  us  to  say  '  this  is  a  typhoid 
fever ; '  it  is  unable  to  determine  which  6f  the  three 
micro-organisms  should  be  incriminated." 

If  the  diagnostic  value  of  the  serum  reaction  is  only 
relative  in  the  non-vaccinated,  what  is  to  be  said  of  it 
in  those  who  have  been  vaccinated  ? 

It  is  known  that  antityphpid  vaccination  causes  the 


120    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

appearance  of  powerful  agglutinins  in  the  blood  serum. 
This  agglutinating  power,  which  may,  exceptionally, 
be  as  high  as  1  in  5000  or  1  in  10,000,  falls  fairly  rapidly 
to  1  in  50  or  1  in  10,  and  even  completely  disappears 
three  or  four  months  after  the  last  injection  of  vaccine. 
This  agglutinating  power  may  be  wakened  into  fresh 
activity  by  any  kind  of  disease  of  a  non-typhoid  nature 
(pneumonia,  appendicitis,  dysentery,  rheumatism,  ordi- 
nary sore  throat,  simple  diarrhoea,  etc.),  and  also  by 
paratyphoid  fever,  when  it  rises  to  a  considerable  figure  : 
1  in  400  six  months  after  antityphoid  vaccination,  1 
in  200  twenty-five  months  after  vaccination  with  five 
injections,  etc.  (Rist,  Coyon). 

However  that  may  be,  at  the  present  time  millions 
of  men  have  undergone  typhoid  and  antityphoid 
vaccination.  Owing  to  this  fact  their  serum  contains 
active  or  latent  agglutinins  for  the  typhoid  bacillus  and 
the  paratyphoid  A  and  B  bacilli. 

The  results  of  the  serum  test,  if  performed  in  such 
cases,  would  be  of  no  value  for  the  diagnosis  of  typhoid 
and  paratyphoid  fevers.  This  is  the  view  of  Leon 
Bernard  and  Paraf  :  "Its  results,  which  were  already 
irregular  and  open  to  suspicion  in  subjects  who  had 
not  been  inoculated,  are  absolutely  useless  in  those 
who  have  been ;  the  application  of  this  method  for 
that  purpose  can  only  give  rise  to  error." 

This  is  also  the  opinion  of  Rist,  who  says,  "  In  those 
who  have  been  vaccinated,  even  with  a  single  injection, 
the  agglutination  test  ought  not  to  be  regarded  as  a 
diagnostic  method.  Not  only  does  it  fail  to  distinguish 
typhoid  fever  from  paratyphoid,  but  it  cannot  even 
serve  to  discriminate  an  infection  of  the  typhoid  group 
from  any  febrile  disease  whatever.  This  diagnosis 
can  only  be  established  by  a  blood-culture  or  clinical 
examination." 

Reservations  must  also  be  made  as  to  the  value  of  the 
clinical  factor. 

This  is  likewise  the  opinion  of  all  those  who  have  been 
working  in  army  laboratories  or  ambulances.  In  the 
light  of  established  facts  they  have,  had  to  give  up  their 


DIAGNOSIS  121 

confidence  in  the  agglutinating  serum  reaction  and 
follow  the  rule  which  H.  Vincent  laid  down  some  time 
ago.  "  The  blood  of  every  inoculated  person  agglutin- 
ates the  typhoid  bacillus  more  or  less.  This  agglutin- 
ating power  may  be  aroused  or  exaggerated  by  any 
kind  of  acute  infection  occurring  in  the  vaccinated. 
No  value,  therefore,  should  be  attributed  to  the  agglu- 
tination test  as  regards  the  diagnosis  of  any  sub- 
sequent illness.  Blood-culture  alone  gives  precise 
information." 

The  reaction  of  fixation  of  the  complement. — The  blood 
serum  of  patients  suffering  from  typhoid  or  para- 
typhoid infections  contains  amboceptors,  which  Widal 
and  Le  Sourd  have  detected  by  the  ordinary  method  of 
fixation  of  the  complement  (Bordet  and  Gengou). 
These  amboceptors,  however,  are  not  strictly  specific 
(Rieux  and  Sacquepee).  In  addition  to  specific  ambo- 
ceptors there  are  group  amboceptors,  as  in  the  case  of 
agglutination. 

It  is  the  same  with  human  serum  as  with  experi- 
mental serum,  and  with  amboceptors  as  with  agglu- 
tinins :  a  real  diagnostic  certainty  is  not  always 
obtained  by  investigating  them. 

Determination  of  the  opsonic  index. — Wright  has 
shown  that  special  substances  are  present  in  normal 
and  pathological  blood  sorum,  which  he  has  called 
opsonins  (opsono  =  I  prepare  food  for),  and  which  are 
indispensable  for  phagocytosis. 

In  pathological  serums  the  amboceptors  not  only 
sensitise  and  bacteriolyse  the  pathogenic  micro-organ- 
ism, but  also  favour  the  phagocytosis.  The  value  of 
this  power  is  determined  fairly  easily  in  practice,  and 
opsonic  index  is  the  name  given  to  the  relation  of  the 
opsonic  power  of  a  pathological  serum  to  the  opsonic 
power  of  a  normal  serum,  their  power  being  calculated 
for  the  same  bacterial  species. 

Milhit  has  shown  that  an  opsonic  index  for  the 
typhoid  bacillus  above  1-70  in  a  suspected  subject  is 
an  element  in  favour  of  typhoid  infection  if  he  has  not 
already  had  typhoid  fever. 


122    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Rathery  has  recently  studied  the  opsonic  index 
of  typhoid  and  paratyphoid  cases  which  have  been 
treated  by  Vincent's  vaccine  known  as  autolysat.  He 
found  that  during  the  disease  the  opsonic  index  of 
these  patients  was  fairly  high.  From  a  practical  point 
of  view  Rathery  thinks  that  it  is  advisable  to  continue 
vaccine  treatment  if  a  fresh  injection  causes  a  definite 
fall  in  twenty -four  hours'  time  of  the  opsonic  index, 
which  rises  again  after  the  second  injection. 


I 


CHAPTER  V 

TREATMENT  OF  TYPHOID  FEVER  AND  PARA- 
TYPHOID FEVERS 

A  NUMBER  of  methods  have  been  suggested  for  the 
treatment  of  typhoid  fever.  These  methods  may  be 
grouped  according  to  the  special  aim  in  view.  We  will 
study  successively  in  separate  sections — 

1.  The  hygiene  of  the  typhoid  patient;  tlie  "little 
attentions  "  that  he  requires. 

2.  The  diet. 

3.  The  methods  emploj^'ed  to  lower  the  temperature. 

4.  Various  measures,  including  antiseptics,  tonics, 
diuretics,  and  methods  for  combating  the  infection. 

5.  Special  treatment  applicable  to  the  principal 
complications  of  typhoid  fever. 

Lastly,  by  way  of  completing  the  methods  of  treat- 
ment indicated  in  the  previous  sections,  and  which  are 
symptomatic  measures  applicable  to  all  typhoid  infec- 
tions indiscriminately,  we  will  describe  the  actual 
state  of  our  knowledge  of  the  specific  treatment  of 
typhoid  and  paratyphoid  fevers  hy  serum  therapy  and 
vaccine  therapy. 

The  hygiene  of  the  typhoid  patient. — As  soon  as 
typhoid  fever  is  suspected,  treatment  should  be 
commenced  at  once,  without  waiting  for  clinical  or 
laboratory  confirmation. 

The  patient  should  be  isolated  as  soon  as  possible 
in  a  large,  well -ventilated  room,  into  which  the  sun  can 
penetrate.  The  mean  temperature  of  the  room  should 
be  about  60°  F.  Carpets,  curtains  and  hangings  should 
be  removed.  If  possible,  two  beds  should  be  placed 
in  the  room,  so  as  to  change  the  patient  from  one  to 

123 


124    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

the  other  if  necessary.  A  waterproof  sheet  should 
be  put  between  the  sheet  and  the  mattress,  and  above 
the  sheet  the  bed  should  be  provided  with  a  draw-sheet 
which  can  be  easily  removed  and  changed  as  soon  as  it 
is  soiled  or  wetted.  The  patient  should  be  clad  in  a 
shirt  or  vest  which  is  completely  open  behind.  Too 
much  light  should  be  avoided,  as  well  as  any  noise, 
conversation  or  visitors.  The  typhoid  patient  needs 
absolute  calm  and  repose. 

The  greatest  attention  must  be  paid  to  the  patient's 
bodily  cleanliness  and  antisepsis.  For  this  purpose  a- 
whole  series  of  precautions  and  methods  are  required 
comprised  under  the  general  description  of  "  little 
attentions  " — a  rather  inaccurate  term,  it  may  be  said, 
for  these  attentions  are  of  the  greatest  importance  in 
the  struggle  with  the  disease. 

Toilet  of  the  month  and  nasal  fossce. — A  dry,  shrivelled 
tongue  constitutes  a  real  danger  in  typhoid  fever 
because  it  prevents  nourishment  being  taken.  It  may 
also  be  a  cause  of  infection  and  dysphagia.  The  tongue 
should  not  present  this  appearance  when  the  patient 
is  well  looked  after  and  well  nursed.  From  the  onset 
of  the  disease  the  nurse  should  be  set  about  cleaning 
the  mouth,  and  under  these  circumstances  it  will  be 
easy  to  keep  it  clean.  If,  on  the  contrary,  she  waits 
for  several  days,  the  tongue,  inside  of  the  cheeks,  teeth 
and  gums  become  covered  with  thick,  hard  and  adher- 
ent crusts  which  will  be  all  the  more  difficult  to  remove 
as  the  patient  will  be  unwilling  to  submit  to  this 
fatiguing,  disagreeable  and  sometimes  even  painful 
operation.  So  from  the  very  beginning  of  the  disease 
the  teeth,  gums  and  tongue  should  be  cleaned  gently 
several  times  a  day  with  a  soft  brush. 

For  this  purpose  a  mixture  of  equal  parts  of  glycerine 
and  eau  de  Vichy  or  eau  de  Vals  should  be  used.  The 
mouth  should  be  washed  out  with  one  of  these  mineral 
waters  or  with  a  four  per  cent,  solution  of  boric  acid. 
The  stringy  mucus  should  be  removed  from  the  pharynx 
by  moist  swabs  of  wool  mounted  on  the  end  of  long 
forceps.     When   the   cleaning  is   finished   the   patient 


TREATMENT  125 

should  be  given  some  drops  of  lemon  juice,  as  they  cause 
a  slight  stimulus  to  the  salivary  secretion.  In  this  way 
the  excretory  channels  will  be  swept  clean.  If  dark 
crusts  are  seen  at  the  back  of  the  mouth,  the  pharynx 
must  be  irrigated  with  boiled  water  from  a  can  con- 
taining hydrogen  peroxide,  twice  in  tlie  twenty-four 
hours  at  least.  These  irrigations  prevent  the  develop- 
ment of  grave  infective  complications  (pharyngeal 
ulceration,  quinsy,  etc.),  which  are  exclusively  due  to 
these  septic  accumulations  of  mucus. 
•  Once  or  twice  a  day  the  patient  may  gargle  or  rinse 
out  his  mouth  with  water  rendered  antiseptic  by  the 
addition  of  a  few  drops  of  Javel  extract. 

By  these  different  methods  it  wiU  be  easy  to  keep 
the  mouth  perfectly  fresh  and  the  tongue  moist  and 
clean. 

After  having  raised  some  difficulty  at  first,  the 
patient  will  afterwards  ask  for  these  attentions  of 
his  own  accord. 

A  careful  watch  should  be  kept  for  the  appearance 
of  lingual,  buccal  or  labial  ulcerations.  As  soon  as 
they  appear  they  should  be  touched  lightly  with 
tincture  of  iodine,  methylene  blue,  chlorate  of  potash 
or  even  formol  (Milhit). 

The  nasal  fossae  must  also  be  cleaned,  and  the  crusts 
removed,  after  they  have  been  softened  with  a  few  drops 
of  menthol  oil  (50  per  cent.),  or  with  menthol  vaseline 
oil,  or,  better  still,  gomenol  vaseline.  Vernier  recom- 
mends the  insertion  into  the  nostrils  of  a  plug  of  oint- 
ment the  size  of  a  pea  of  the  following  composition — 

Vaseline     .      .      .      .      .      .20       grammes 

Boric  acid 2  ,, 

Resorcin 0*15         ,, 

Menthol     ......       0-05 

The  lips  should  be  washed  with  warm  boracic  lotion. 
Attention  must  be  paid  to  the  ears,  and  the  patients 
prevented  from  scratching  their  nose,  nasal  fossae,  etc. 

Hygiene  of  the  skin.  The  frequency  of  boils  in  con- 
valescence from  typhoid  fever  is   well   known.     The 


126    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

origin  of  these  secondary  infections  of  the  skin,  which 
may  sometimes  assume  the  character  of  phlegmonous 
inflammation  and  grave  septicaemia,  is  often  neglect 
of  cutaneous  asepsis. 

Asepsis  of  the  skin  should  be  carried  out  in  the 
following  way.  Plugs  of  cotton-wool  containing  carbol- 
ised  glycerine  may  be  placed  in  the  ears.  In  addition 
to  baths,  the  skin  should  be  sponged  all  over  with  cold 
or  warm  water  containing  thymol,  antiseptic  or  aro- 
matic vinegar,  or  eau  de  Cologne.  All  the  parts  which 
have  been  soiled  by  the  urine  or  fseces  should  also  be 
washed  by  sponging  rather  than  by  rubbing  the  skin 
with  damp  wool.  After  each  washing  the  parts  should 
be  gently  dried.  Every  folliculitis  lesion  should  be 
touched  gently  with  iodine  or  iodine -acetone.  As 
soon  as  the  formation  of  a  little  vesicle  filled  with  pus 
is  observed,  the  pus  should  be  evacuated  aseptically 
and  the  little  wound  painted  with  iodine. 

One  must  be  on  the  look  out  for  infections  due  to 
streptococci,  staphylococci  or  B.  pyocyaneus,  and 
treat  them  if  thej^  appear  with  tincture  of  iodine  or 
peroxide  of  hydrogen. 

In  some  cases,  when  the  infection  is  generalised, 
recourse  should  be  had  to  antiseptic  baths,  preferably 
boracic  acid  (200  grammes  per  bath),  to  which  has  been 
added  a  little  eau  de  Javel  (liquor  sodse  chlorinatse). 
As  prolonged  pressure  in  association  with  maceration 
may  cause  trophic  disturbances  of  the  skin,  especially 
bedsores,  attention  must  be  paid  to  the  patient's 
position  in  bed,  and  he  must  be  dried  carefully  after 
sponging  or  baths.  He  should  never  be  left  too  long 
in  the  same  position.  Several  times  a  day  he  should 
be  made  to  change  into  a  different  position,  such  as 
the  right  or  left  lateral  decubitus,  the  dorsal  decubitus, 
or  a  half-sitting  position,  by  supporting  him  with 
cushions  or  pillows.  As  ulcerations  in  typhoid  patients 
have  a  rapid  course,  as  soon  as  a  redness  is  seen, 
especially  in  the  gluteal  region,  after  making  the  skin 
aseptic  it  should  be  dusted  with  subnitrate  of  bismuth 
and    finely-pulverised    Lucas- Championniere     powder, 


TREATMENT  127 

and  care  should  be  taken  that  the  patient  should 
always  rest  on  a  thick  layer  of  heavily-powdered 
wool. 

If  the  subject  is  fat,  the  natal  cleft  down  to  the  anus 
should  also  be  powdered  after  washing.  If  a  slight 
ulceration  appears,  it  should  be  painted  with  tincture 
of  iodine  and  then  powdered,  and  the  region  should 
be  supported  on  a  rubber  ring.  If  the  patient  is  thin, 
a  water  bed  should  be  used. 

The  hair  should  be  cut  at  the  beginning  of  the  disease, 
which  can  easily  be  done  in  men ;  as  this  practice  has 
certain  disadvantages  in  the  case  of  women,  their  hair 
should  be  plaited  in  two  or  three  very  close  plaits, 
which  should  be  wetted  as  little  as  possible  during  the 
baths.  In  convalescence  the  plaits  should  be  undone 
for  a  short  time  every  day,  for  five  to  ten  minutes  at 
most,  after  oiling  the  scalp.  The  head  may  be  washed 
with  Panama  soap  and  shampooed  with  St.  Louis 
lotion  (ammonia  4  grammes,  oil  of  turpentine  25 
grammes,  camphorated  alcohol  125  grammes). 

Good  results,  especially  in  children,  may  be  obtained 
with  Comby's  prescriptions. 

The  Lotion 

Castor  oil    .     .     . 30  grammes 

Alcohol  60  per  cent 100  „ 

Tincture  of  quinine ^  — 


imcture  oi  qumine ^  — 

Tincture  of  rosemary V   - 

Tincture  of  Jaborandi J 


or 


The  Ointment 

Vaseline 30  grammes 

Lanoline 10  „ 

Balsam  of  Peru 2  „ 

Gallic  acid 1         „ 

To  be  rubbed  into  the  scalp  morning  and  evening. 

Hygiene  of  the  genito-urinary  system. — Ulceration  of 
the  vulva  is  not  uncommon  in  typhoid  fever.  In  the 
case  of  little  girls  the  parts  should  be  washed  carefully 


128    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

every  day  with  soap  and  water.  In  women  one  should 
ofder  vaginal  douches  of  a  1  in  400  permanganate 
solution,  followed  by  washing  the  vulva  with  soap.  In 
severe  typhoid  fever  one  may  have  to  catheterise  the 
patient.  In  such  cases  the  greatest  antiseptic  pre- 
cautions must  be  taken  ;  if  infection  is  likely  to  occur 
the  bladder  should  be  systematically  washed  out  with 
250' c.c.  of  a  very  weak  hot  solution  of  permanganate  of 
potash. 

Diet  of  the  typhoid  patient.  The  diet  of  the  typhoid 
patient  is  of  the  utmost  importance.  The  typhoid 
patient  must  receive  nourishment,  but  in  practice 
views  differ  as  to  the  nature  of  this  nourishment. 
Generally  speaking,  in  France  the  diet  prescribed  is 
fluid  or  semi-fluid.  It  chiefly  consists  of  milk.  The 
patient  should  take  a  minimum  of  three  to  four  litres 
of  fluid  in  the  twenty-four  hours,  two  of  which  should 
consist  of  milk.  The  milk  should  be  given  only  after 
it  has  been  boiled  for  at  least  ten  minutes.  It  should 
be  kept  in  a  cool  place  in  closed  receptacles.  It  may  be 
given  pure  or  diluted  with  eau  de  Vichy  or  eau  de  Vals, 
or  hot,  warm  or  cold,  and  with  or  without  sugar.  If 
the  patient  wishes  it,  there  is  no  harm  in  flavouring 
it  with  small  quantities  of  tea,  coffee,  rum,  cognac, 
kirsch,  orange-flower  water,  vanilla,  essence  of  aniseed 
(one  drop  per  cup),  or  in  making  it  acid  or  frothy,  etc. 
After  each  feed  of  milk  it  is  well  to  wash  out  the  mouth 
with  eau  de  Vichy,  ptisan,  orangeade,  etc.  If  the  milk 
is  well  tolerated,  the  quantity  may  be  increased  to 
two  and  a  half  litres  a  day.  Sometimes,  although  it 
has  been  boiled  and  had  not  gone  sour,  it  may  cause 
diarrhoea  and  distension.  It  should  be  given  in  feeds 
of  about  fifty  grammes  at  a  time,  to  which  lime  water  or 
citrate  of  soda  (in  a  dose  of  two  grammes  per  litre  of 
milk)  have  been  added.  Asses'  or  goats'  milk  may  be 
tried.  In  case  of  absolute  intolerance,  recourse  should 
be  had  to  kefir  or  koumiss.  Silby  uses  whey  in 
amounts  varying  from  one  to  three  and  a  half  litres  per 
day,  flavoured  with  tea  or  coffee.  Lastly,  in  some 
cases  milk  will  have  to  be  given  up  altogether  and 


TREATMENT  129 

replaced  by  vegetable  soup/  cereal  decoctions,^  or  soups 
containing  flour,  and  eggs  and  very  light  custards. 

Besides  milk,  the  patient  may  take  every  hour,  or 
every  half-hour,  half  a  glassful  or  a  glassful  of  such 
drinks  as  wine  diluted  with  lemonade,  weak  tea  or 
coffee,  weak  grog,  lemonade,  orangeade,  fruit  syrups 
much  diluted  with  water,  slightly  alkaline  mineral 
waters  (Vichy-Celestins,  Vals),  and  diuretic  decoctions 
(couch-grass,  cherrj'^  stalks,  liquorice,  etc.).  The  drinks 
may  be  given  warm,  at  the  room  temperature,  or  even 
iced.  They  should  not  be  made  too  sweet,  as  an  excess 
of  sugar  may  increase  intestinal  fermentation.  Lac- 
tose, which  is  diuretic,  may  be  used,  in  a  dose  of  100- 
200  grammes  per  diem,  to  sweeten  the  drinks. 

The  patient  should  drink  often,  but  little  at  a  time, 
and  very  slowly. 

Apart  from  exceptions  based  on  the  general  state, 
appearance  of  the  tongue  and  the  temperature,  he 
should  not  be  woken  up  for  a  drink,  but  all  suitable 
occasions  should  be  made  use  of.  The  best  times,  and 
those  when  he  will  be  most  ready  for  a  drink,  are  after 

^  Vegetable  soups  are  much  used  in  the  treatment  of  children's 
diseases.  Among  the  numerous  prescriptions,  Mery's  formula  is 
to  be  recommended. 

Potatoes 60  grammes 

Carrots 45  „ 

Turnips 15  „ 

Dried  peas  . 6  „ 

Dried  beans "...       6  „ 

Cold  water  . 1  litre 

Salt 5  grammes 

Boil  for  two  hours ;  filter ;  make  the  filtrate  up  to  a  litre  by  adding 
cold  boiled  water.     Add  5  grammes  of  salt. 


Barley    . 
Pearl  barley 
Pounded  maize 
Shelled  beans    . 
Shelled  peas 
Shelled  lentils  . 


30  grammes  or  a 
ladleful  of  each 


Boil  for  three  hours  in  a  litre  of  water,  add  5  grammes  of  salt  and 
strain. 


130    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

the  cleaning  of  the  mouth,  and  during  and  after  the 
bath  at  the  moment  of  reaction. 

Milk  and  drinks  are  not  always  sufficient  nourish- 
ment for  typhoid  patients. 

Robin  adds  a  litre  of  veal  or  chiclcen  broth  in  the 
twenty-four  hours. 

It  rarely  happens  in  the  course  of  typhoid  fever  of 
moderate  intensity  that  one  can  make  the  patient  take 
all  the  nourishment  he  needs.  As  a  rule  he  takes  much 
less.  Sometimes,  even,  he  refuses  all  nourishment.  One 
is  forced  to  feed  him  by  a  tube,  or,  which  is  much  less 
desirable,  carefully  give  him  nutrient  enemata  con- 
taining milk  and  peptone  and  the  yolk  of  an  egg.  The 
patient's  refusal  to  take  food  is  hardly  ever  persistent ; 
in  a  few  days'  time  he  usually  consents  to  take  any 
kind  of  nourishment. 

The  regime  which  w^e  described  stiould  be  continued 
till  the  time  when  the  temperature  has  definitely  fallen 
and  keeps  below  98-6°.  As  soon  as  the  general  con- 
dition improves  and  the  temperature  falls  to  about 
98-6°,  the  patient  begins  to  have  a  craving  for  food. 
The  doctor  must  make  the  convalescent  understand 
that  a  too  hasty  return  to  substantial  food  exposes  him 
to  a  relapse,  which  may  be  grave,  and  even  fatal.  The 
patient's  attendants  and  family  should  be  warned  of 
all  the  dangers  that  may  be  caused  by  indulging  the 
convalescent's  immoderate  appetite  even  in  a  slight 
degree. 

As  a  general  rule,  while  the  temperature  fluctuates 
between  98-6  and  99*6°  he  may  take  three  litres  of  milk 
or  broth.  He  may  also  be  given  a  light,  well -cooked 
tapioca  pudding. 

If  the  temperature  keeps  at  about  98-6°,  one  may 
gradually  try  a  little  more  substantial  diet,  for  very 
often  inanition  in  emaciated  and  debilitated  subjects 
is  enough  to  maintain  a  slight  rise  of  temperature,  which 
disappears  as  soon  as  the  patient  takes  a  little  more 
nourishment.  But  in  most  cases  one  must  wait  till 
the  temperature  has  been  normal  for  three  or  four  days., 
Then,  very  cautiously,  keeping  an  eye  on  the  tempera- 


TREATMENT  131 

ture  and  the  vstools,  one  may  give  a  little  weU-cooked 
tapioca  or  semolina  in  some  meat  or  chicken  broth, 
with  the  daily  addition  of  the  yolks  of  one  or  two  eggs. 
If  the  temperature  does  not  rise  the  patient  may  take 
two  soups  of  a  somewhat  thicker  consistency,  and  then 
purees.  Lastly,  he  may  be  allowed  a  small  piece  of 
stale  bread,  without  crust,  in  the  soup,  with  a  boiled 
egg  and  jam,  and  then  successively  a  little  iresh  fish, 
chicken,  beef  or  mutton,  with  the  order  to  eat  it  slowly 
and  masticate  it  well.  If  the  fever  reappears,  he  should 
return  immediately  to  milk  and  broth.  If  the  patient 
does  not  have  a  stool  daily,  his  bowels  should  be  moved 
by  prunes,  stewed  fruit,  or  an  enema  of  cold  water. 

Such  is  the  diet  which  almost  all  French  physicians 
have  ordered  their  patients.  Other  scales  of  diet  have 
been  advocated. 

Johnson  and  Watt  do  not  give  milk  until  convales- 
cence. Their  patients'  diet  is  composed  of  soup  made 
of  barley  meal,  rice,  oats,  eggs  and  sugar.  They  use 
large  quantities  of  gelatin. 

This  diet  cannot  escape  criticism.  In  addition  to 
its  nutritive  properties,  milk  has  also  diuretic  properties 
which  the  most  nutritious  broth  does  not  possess. 
Gelatin  may  combat  and  even  prevent  diarrhoea  and 
haemorrhage,  but  it  is  not  nutritious,  and,  even  by 
flavouring  it,  it  is  difficult  to  mask  its  disagreeable  taste 
and  make  the  patient  take  fifty  grammes  of  it  daily 
for  several  weeks. 

A  certain  number  of  Russian  authors  (Gournitzki, 
Botkine,  Puritz,  etc.)  and  Vaquez,  in  France,  with  the 
object  of  preventing  excessive  emaciation  and  shorten- 
mg  the  duration  of  convalescence,  give  substantial 
nourishment  to  their  patients. 

They  maintain  that  the  temperature  is  not  increased, 
the  risks  of  perforation  and  haemorrhage  not  greater, 
nor  relapses  more  frequent  in  consequence  of  their 
method.  Although  he  does  not,  like  the  Russian 
authors,  go  so  far  as  to  give  his  typhoid  patients  soup, 
rissoles,  cutlets  and  potatoes,  Vaquez's  diet  is  neverthe- 
less a  very  generous  one.     Every  two  hours  the  patient 


132    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

has  a  cup  of  milk,  but  at  8  a.m.,  noon  and  6  p.m.  a 
small  meal  may  be  substituted  for  this  cup  of  milk.  At 
8  a.m.,  a  cup  of  tea  or  coffee  and  mUk,  or  a  plate  of 
farinaceous  soup  (raccahout,  barley  or  rice) ;  at  noon, 
bread  and  milk  with  a  yolk  of  an  egg,  a  wineglassful 
of  meat  jell 3^  or  cold  meat  juice ;  at  6  p.m.,  the  same 
meal  but  with  some  broth  with  an  egg  beaten  up  substi- 
tuted for  the  bread  and  milk.  In  the  night  a  similar 
little  meal  with  milk.  The  principal  meals  are  given 
on  leaving  the  bath.  When  the  temperature  falls, 
grated  raw  meat,  such  as  mutton  or  pork,  is  given. 
Then  various  soups,  rice  pudding  and  potatoes,  until 
on  the  eighth  day  of  convalescence  the  patient  is  given 
biscuits,  boiled  eggs,  etc. 

This  method  has  been  criticised.  In  any  case,  it  is 
not  suitable  for  severe  attacks. 

Claisse  gives  a  small  meal  every  four  hours  to  his 
typhoid  patients  who  cannot  digest  milk.  Farinaceous 
foods  and  sugar  predominate  in  his  diet  scale ;  potato 
purees,  light  soups,  semolina  cakes,  fruit  jellies  and 
fruit  juice,  with  cocoa  and  butter.  He  does  not  give 
milk  till  convalescence,  when  he  also  gives  eggs,  and 
then  meat.  He  adds  after  some  time  to  his  diet 
cultures  of  the  paralactic  bacillus. 

Thomson,  in  cases  in  which  the  temperature  is  not 
high,  suppresses  the  milk  or  reduces  it  considerably, 
adding  meat  juice,  lactose,  white  of  egg,  and  light 
broths.  In  the  first  days  of  apyrexia,  if  the  patient 
has  no  diarrhoea  or  distension,  and  has  not  had  haemor- 
rhage recentl}'',  his  diet-scale  consists  of  pastry,  sweets, 
lightly-cooked  eggs,  rice,  milk,  biscuits,  mutton  or 
chicken  broth,  meat  jellies  and  farinaceous  soups. 
The  doctor  can  modify  the  diet  according  to  the  indi- 
cations furnished  by  each  particular  case.  He  should 
only  remember  that  the  diet  of  the  typhoid  patient 
must  be  at  once  substantial  and  perfectly  assimilable, 
that  all  the  digestive  secretions  are  deficient  in  these 
patients,  and  that  one  must  not  force  upon  them  a 
diet  which  cannot  be  easily  digested ;  that  it  should 
not   contain   any  solid    particle   which  is   capable    of 


TREATMENT  133 

mechanically  irritating  the  intestine  ;  and  that,  finally, 
it  should  not  be  distasteful  to  the  patient,  who  has 
already  too  great  a  tendency  not  to  take  enough 
nourishment. 

Antipyretic  Measures 

One  of  the  first  indications  in  typhoid  fever  is  to 
lower  the  temperature.  This  result  may  be  obtained 
by  external  applications  or  internal  treatment. 

External  applications  comprise  a  certain  number  of 
hydro -therapeutic  measures,  such  as  affusions,  wet 
packs,  sponging,  baths,  applications  of  ice,  compresses 
and  enemata. 

Sponging. — Sponging,  which  was  introduced  by 
Jaccoud,  can  easily  be  employed  at  any  time  or  place, 
and  may  be  sufficient  in  the  treatment  of  slight  or 
moderate  attacks.  According  to  0.  Martin,  intestinal 
haemorrhage,  myocarditis,  or  a  tendency  to  collapse 
should  contra-indicate  its  use,  but  Milhit,  on  the  con- 
trary, says  that  sponging  is  indicated  in  all  syncopal 
or  hsemorrhagic  forms.  Pulmonary  complications  are 
not  a  contra-indication.  They  may  be  given  with  cold 
(53-6-59°  F.)  or  warm  water.  The  •  duration  of  the 
sponging  must  not  exceed  three  minutes ;  the  colder 
the  water  the  shorter  it  must  be.  The  patient  lying  at 
full  length  naked  on  the  bed,  a  large  sponge  is  rapidly 
passed  all  over  his  body,  soaked  Avith  water  which  is 
either  plain  or,  better  stUl,  contains  eau  de  Cologne  or 
aromatic  vinegar.  The  patient  is  then  rolled  in  a  blanket 
and  given  a  hot  alcoholic  drink.  He  is  left  thus  for 
fifteen  to  twenty  minutes,  and  then  wiped  without 
touching  the  abdomen.  Two  to  ten  or  twelve  spongings 
may  be  given  in  this  way  as  a  substitute  for  baths. 

Although  its  action  on  the  temperature  is  very  slight, 
sponging  is  nevertheless  extremely  useful  owing  to 
the  sense  of  comfort  which  it  induces  as  a  result  of  the 
sedative  influence  on  the  nervous  symptoms  and  the 
stimulating  action  on  the  prostration. 

Affusions. — Affusions  are  an  old -standing  practice. 


134    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

having  been  introduced  by  Currie  and  employed  in 
France  by  Recamier,  Chomel,  Trousseau,  Gueneau  de 
Mussy,  etc.  Contra-indications  to  their  use  are  the 
same  as  in  sponging,  or  even  stronger.  Besides, 
patients  do  not  support  them  well.  Baths  are  to  be 
preferred  if  a  fall  of  the  temperature  is  desirable. 
"  The  patient  is  placed  in  a  bath,  and  two  persons  in 
rapid  succession  pour  cold  water  of  50-59°  F.  on  his 
head  and  back  for  some  minutes ;  if  a  douche  is  avail- 
able, its  duration  should  be  very  short,  and  not  exceed 
one  to  two  minutes  "  (Gueneau  de  Mussy).  The  fall 
of  temperature  obtained  is  on  an  average  0-9-l-0°F. 

Wet  Packs. — Wet  packs,  consisting  of  a  moistened 
sheet,  are  to  be  recommended  chiefly  for  children.  They 
calm  restless  patients  and  make  them  sleep.  Their 
technique  is  simple.  A  sheet  is  plunged  into  cold  water, 
wrung  out  vigorously  and  spread  on  a  blanket.  The 
patient  is  placed  naked  on  the  sheet  and  wrapped  up 
completely  in  it.  He  is  left  thus  for  about  a  minute, 
then  wiped  and  put  back  to  bed.  This  method  of 
reducing  the  temperature  is  a  rather  brutal  one.  It 
causes  a  shock  to  the  typhoid  patient  and  provokes 
intense  distress,  and  sometimes  even  syncope. 

Treatment  by  baths. — Balneotherapy  is  the  treat- 
ment of  choice  in  typhoid  fever.  Not  only  does  it 
cause  a  remarkable  fall  in  temperature,  but  by  its 
remote  effects  especially  it  possesses  a  very  real  and 
efficacious  therapeutical  action.  The  most  certain 
and  best  studied  of  these  effects  are  :  improvement  in 
the  pulse  and  arterial  tension,  which  indicate  improve- 
ment in  the  cardiac  tone ;  calming  of  the  nervous 
symptoms ;  increase  in  diuresis  and  the  intestinal 
secretions ;  diminution  of  the  dryness  of  the  mouth 
and  stimulation  of  respiratory  oxidation. 

Brand's  method. — Currie  (1787)  introduced  this 
method,  which  Brand  (1861)  appropriated  and  codified, 
and  Glenard  (of  Lyons)  introduced  into  France. 
Brand's  complete  method  consists  in  giving  the  patient, 
night  and  day  every  three  hours,  a  cold  bath  for  a 
quarter  of  an  hour  at  64-4°  F.  if  the  rectal  temperature 


TREATMENT  135 

is  above  102-2°  F.  To  attenuate  the  disagreeable 
impression  caused  by  the  first  bath,  it  may  bo  given  at 
71-6°  F.  The  following  baths  are  each  lowered  by 
1-8°  F.,  so  that  the  fifth  would  be  at  the  desired  tem- 
perature of  64-4°  F.  (Brand,  Juhel-Renoy). 

Cold  affusions  are  given  by  pouring  water  at  50°  F. 
on  the  nape  of  the  neck  from  just  above  the  head  for 
two  minutes  each  time. 

Tripierand  Bouveret  recommend  continuous  affusion. 

As  soon  as  the  patient  enters  the  bath  he  is  given  a 
drink  of  brandy  or  wine.  About  ten  minutes  after  the 
commencement  of  the  bath  he  is  seized  with  intense 
shivering.  This  is  the  signal  for  the  bath  to  end,  |Ie 
is  given  another  drink  of  brandy  or  wine  and  placed  at 
full  length  on  the  bed,  on  which  has  been  previously 
laid  a  blanket  covered  with  a  warm  dry  sheet.  He  is 
then  wiped  quickly  and  gently  without  touching  the 
abdomen,  wrapped  up  in  a  blanket,  with  a  hot  bottle 
at  his  feet,  and  left  to  shiver.  In  a  quarter  of  an 
hour  or  half  an  hour's  time  general  relief  is  experienced. 
The  patient  feels  better,  and  after  he  has  been  clad  and 
given  a  drink  he  usually  goes  to  sleep. 

In  severe  hyperpyretic  and  adynamic  fevers  in 
which  the  heart,  kidnej^s  and  lungs  are  severely  affected, 
the  a-dvocates  of  Brand's  method  employ  a  special 
technique  until  improvement  sets  in,  called  the  intensive 
method,  of  which  Juhel-Renoy  gives  the  following  de- 
scription. A  first  bath  is  given  at  78-8°,  a  second  at 
75-2°,  and  so  on,  diminishing  each  bath  by  3-6°  F.,  so 
that  by  the  eighth  bath  the  regulation  temperature  of 
64-4°  F.  is  reached.  The  duration  of  the  bath  will  be 
shorter  :  eight  to  ten  minutes.  Shivering  is  to  be 
obtained  and  prolonged  by  lowering  the  temperature  of 
the  bath  to  59-0°.  Cold  affusions  (46-4-50°  F.)  should 
be  carried  on  throughout  the  duration  of  the  baths,  with 
massage  and  friction  of  the  limbs  under  water.  Large 
thoracic  and  abdominal  compresses  are  absolutely 
necessary.  If  the  patient  shows  the  least  sign  of  get- 
ting worse  he  should  be  put  in  a  bath  again  every  two 
•hours  instead  of  every  three  hours,  and  if  the  heart 


136    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

shows  signs  of  weakness,  an  ice-bag  should  be  placed 
on  the  prsecordial  region. 

Such  is  Brand's  method,  which  involves  no  form  of 
treatment  besides  the  baths.  According  to  its  advo- 
cates, its  only  contra-indications  are  profuse  intestinal 
haemorrhage  and  perforation. 

A  method  of  this  kind  rigorously  carried  out  is  not 
suitable  for  all  patients,  and  especially  for  women  and 
children,  or  nervous  and  impressionable  patients,  or 
for  soldiers  coming  from  the  trenches  exhausted  both 
by  the  infection  and  overwork.  In  a  hospital  where  the 
best  installation  and  nursing  were  available,  it  yielded 
a  mortality  of  19-5  per  cent.  (Petges,  Dumora  and 
Peyri).  Whatever  may  be  its  advantages,  in  ordinary 
cases  equally  good  results  may  be  obtained  by  milder 
methods  which  are  less  disagreeable  to  the  patient. 

Warm  or  tepid  baths  (89-6-82-4°  F.),  which  con- 
stitute a  mild  form  of  Brand's  method,  regulate  the 
temperature  curve  in  the  same  way. 

Nervous  and  excitable  patients,  as  well  as  children, 
support  them  better  than  cold  baths  and  derive  more 
marked  benefit  therefrom.  These  baths  may  be  of 
short  duration — ten  minutes,  for  example,  with  or  with- 
out cold  affusions  on  the  nape  of  the  neck  at  the  end  of 
the  bath  (Grasset) — or  be  prolonged  even  for  a  whole 
day  (Riess). 

Warm  baths  gradually  chilled. — In  the  chilled  bath 
the  advantages  of  the  cold  bath  are  retained  without 
those  properties  which  are  unnecessary  or  disagreeable 
to  the  patient.  This  method  was  introduced  by 
Bouchard,  who  uses  a  bath  whose  temperature  is 
3-6°  F.  below  that  of  the  patient.  By  adding  cold 
water  the  bath  is  gradually  refrigerated  by  1-8°  F.  every 
ten  minutes.  .  When  the  water  is  at  86° F.,  the  chilling 
is  stopped,  and  the  patient  is  taken  out  of  the  bath. 
The  higher  the  temperature  of  the  patient,  the  longer 
these  baths  may  be  continued.  They  are  repeated 
six  to  eight  times  in  the  twenty -four  hours.  Can-ieu 
reduces  the  duration  of  the  bath  to  a  maximum  of  an 
hour,  starting  with  a  temperature  of  98-6°,  and  chilling 


TREATMENT  137 

it  sometimes  more  rapidly  by  adding  cold  water  every 
five  minutes  until  it  reaches  86-0°. 

He  gives  five  or  six  baths  on  the  average  ;  often  less, 
rarely  more,  being  guided  by  the  initial  temperature 
for  the  day.  If  three  hours  after  a  bath  the  patient's 
temperature  has  not  fallen  by  1-8°  below  his  initial 
temperature,  he  gives  another  bath;  but  if  it  has,  he 
waits  an  hour  or  more. 

In  some  forms  of  typhoid  fever,  with  hyperpyrexia 
and  nervous  phenomena,  cold  baths,  which  should  be 
repeated  as  often  as  is  necessary,  still  constitute  the 
real  treatment.  It  is  most  important  not  to  delay,  and 
to  employ  them  jrom  the  beginning  of  the  disease, 
regulating  the  number  of  the  baths  by  the  patient's 
temperature. 

Hot  baths. — Bosc  advocates  hot  baths  at  102-2°  F., 
and  from  twelve  to  fifteen  minutes  in  duration.  They 
gave  him  good  ]:esults  in  the  treatment  of  cholera,  a§ 
well  as  in  severe  broncho -pneumonia  and  bronchitis. 
According  to  him,  these  warm  baths  have  an  elimi- 
natory,  sedative,  revulsive  and  antiphlogistic  action,  as 
well  as  a  regenerative  effect  upon  the  myocardium. 
Bosc  recommends  them  for  children  who  violently 
object  to  cold  baths,  and  for  cases  with  grave  respiratory 
complications,  anuria  or  diminution  of  the  urinary 
secretion,  severe  delirium,  or  when  the  heart  is  mucjfi 
affected.  In  the  adult  "  the  two  most  formal  indica- 
tions— i.e.  those  in  which  no  other  method  can  be  per- 
mitted— are  {a)  in  cases  where  the  cold  bath  is  contra- 
indicated  owing  to  the  state  of  the  heart ;  (&)  in  the 
case  of  the  hsemorrhagic  form  of  typhoid  fever,  and  espe- 
cially in  hsemorrhagic  nephritis  with  headache,  nausea 
and  vomiting,  suggesting  an  ursemic  complication  " 
(0.  Martin). 

Whatever  the  mode  of  bath  treatment  adopted, 
there  are  certain  rules  which  must  always  be  followed. 
The  patient  should  not  make  any  effort.  He  should  be 
carefully  carried  from  his  bed  to  the  bath,  which 
should  be  near  at  hand,  in  the  same  room.  He  should 
never,  in  any  case,  go  there  by  himself,  owing  to  the 


138    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

risk  of  intestinal  perforation,  syncope  or  sudden  death. 
The  water  in  the  bath  should  be  changed  very  often, 
at  each  bath  if  possible,  or  at  least  once  in  the  twenty- 
four  hours.  The  patient's  buttocks  should  be  slightly 
vaselined  before  the  bath.  Grave  infective  complica- 
tions may  sometimes  originate  from  baths  given  with 
water  contaminated  by  faeces,  and  the  water  should 
have  a  mild  antiseptic  put  in  it  (boracic  acid,  cresyl, 
naphtholate  of  soda,  iiquor  sodaB  chlorinatse). 

Advantage  should  be  taken  of  the  bath  to  clean  the 
patient's  mouth  and  give  him  a  warm  drink  systemati- 
cally. The  typhoid  patient  should  never  be  left  alone, 
even  for  a  minute,  during  the  bath.  .In  some  cases 
the  doctor  should  give  the  bath  himself,  and  carefully 
watch  the  pulse  meanwhile. 

On  leaving  the  bath,  the  patient  should  never  be 
rubbed  down  or  wiped  dry.  He  should  be  put  on  his 
bed  wrapped  up  in  a  blanket,  and  the  reaction  should 
be  waited  for.  The  beginning  of  the  phase  of  reaction 
is  an  indication  for  giving  him  another  drink.  If  this 
phase  is  too  prolonged  or  is  unsatisfactory,  the  patient 
should  be  warmed  by  hot  drinks,  and  given  coffee,  and 
the  following  bath  must  be  shorter  and  hotter. 

There  is  an  absolute  contra-indication  if  intestinal 
perforation  or  commencing  peritonitis  is  suspected. 
If  there  is  considerable  intestinal  haemorrhage  which  is 
repeated,  the  baths  should  be  stopped  for  a  few  days 
and  then  resumed,  a  careful  watch  being  kept  upon  the 
patient,  or  cold  sponging  should  be  substituted. 

Baths  should  also  be  discontinued  if  phlebitis  occurs. 
The  appearance  of  a  cardiac  complication  requires  the 
presence  of  the  doctor  during  the  bath,  so  as  to  guard 
against  a  possible  fainting  attack. 

With  these  exceptions,  baths  have  no  other  serious 
contra -indications ;  they  should  not  be  prevented  by 
pulmonary  congestion,  bronchitis  or  menstruation. 

Compresses. — Brand  borrowed  from  Jacquez  (of 
Lure)  the  method  of  cold  water  compresses,  which  are 
placed  on  the  abdomen,  thorax,  head  and  even  the 
whole  body,  and  frequently  changed.     Cheinisse  recom- 


TREATMENT  139 

mends  the  direct  application  to  the  abdomen  of  a 
compress  soaked  in  90  per  cent,  alcohol  and  wrung 
out.  The  compress  is  covered  with  a  layer  of  wool 
soaked  in  cold  water,  on  -v^hich  is  placed  a  piece  of 
mackintosh,  and  the  whole  is  kept  in  position  by  a 
flannel  bandage.  The  water  compress  is  changed  every 
hour,  and  the  alcohol  compress  every  two  hours, 

Enemata. — In  1875,  Foltz  (of  Lyons)  proposed  the 
administration,  every  three  or  four  hours,  of  a  litre  of 
cold  water  of  a  temperature  of  50-59°  F.  'per  rectum. 
Nowadays  large  injections  or  enteroclysis  are  preferred, 
consisting  of  three  to  four  litres  at  a  low  pressure  by 
the  use  of  a  sufficiently  long  tube.  Two  enemata  of 
boiled  water  are  given  daily  at  a  temperature  of  64-4- 
68°  F.  if  preferred  cold,  or  at  104-107-6°  F.  if  hot. 
Hot  enemata  appear  to  be  more  diuretic  than  cold, 
though  the  latter,  on  the  other  hand,  bring  down  the 
temperature  more.  Whether  cold  or  hot,  they  clear 
the  intestine  of  debris  and  putrid  products,  aUow  the 
absorption  of  fluids,  and  may  serve  as  a  vehicle  for  anti- 
septics which  will  disinfect  the  lower  part  of  the  intes- 
tine. Thus  to  the  boiled  water  can  be  added  boracic 
acid,  phenosalyl,  in  doses  of  5  grammes  per  litre,  or 
liquor  sodae  chlorinatse,  in  doses  of  10  grammes  per 
litre. 

Drop  hy  drop  method. — The  intra-rectal  instillation  of 
a  solution  of  glucose  or  cane  sugar  in  a  strength  of  50 
or  60  per  1000,  drop  by  drop,  gives  excellent  results, 
rapidly  causes  the  headache  and  general  discomfort'  to 
disappear,  and  at  the  same  time  increases  the  urinary 
secretion  (P.  Emile  Weill,  F.  Rathery,  J.  Carles,  etc.). 
It  should  be  given  hot  (122°  F.)  and  very  slowly.  Three 
hours  at  least  are  needed  for  the  instillation  of 'a  litre 
of  fluid.  Under  these  conditions  only  can  the  patient 
keep  and  absorb  the  fluid.  If  necessary,  adrenalin  or 
chloral  can  be  added  to  the  sugar  solution. 

Refrigeration  hy  cold  air. — J.  Sabrazes  has  had  re- 
course to  refrigeration  of  the  typhoid  patient  by  cold 
air,  thus  reviving  the  simple,  practical  and  efficacious 
method  of  James  Sims  (1778). 


140    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Internal  medication. — Generally  speaking,  as  few 
drugs  as  possible  should  be  given  in  typhoid  fever. 
They  fatigue  and  irritate  the  stomach,  sometimes 
provoke  vomiting,  and,  with  the  exception  of  special 
and  definite  cases,  are  of  little  service  (Lemoine  and 
Gerard,  Dieulafoy).  As  regards  the  antipyretic  drugs 
which  have  been  recommended,  we  will  say  a  few  words 
about  those  most  commonly  employed. 

Cryogenine  should  be  used  only  when  the  urine  is 
abundant.  Apart  from  its  antipyretic  action,  it  is 
analgesic,  and  causes  the  headache  to  disappear  entirely. 
The  dose  for  an  adult  is  0-30  gramme.  It  is  well  to 
know  that  it  colours  the  urine  yellow,  and  that  some 
typhoid  patients  suffer  from  severe  hypothermia,  with 
collapse,  even  after  10  centigrammes  of  the  drug. 

Pyramidon,  even  in  very  small  doses  and  combined 
with  caffeine,  may  cause  profuse  greenish  vomiting, 
with  pronounced  contraction  of  the  abdomen  and  a 
fall  of  temperature  to  98-2°,  suggesting  perforation 
(Hirtz) ;  it  may  also  produce  severe  symptoms  of 
collapse  (Rist,  Brault). 

Antipyrine,  whether  combined  or  not  with  bicar- 
bonate of  soda,  has  an  injurious  action  both  on  the 
heart  and  kidneys ;  it  diminishes  the  elimination  of 
toxic  products.  These  two  drugs,  therefore,  should 
not  be  generally  employed. 

Quinine  should  not  be  used  for  lowering  the  tempera- 
ture. It  has  no  antipyretic  action  in  the  course  of  the 
disease.  It  may  be  employed  as  a  tonic  (Robin, 
Lemoine  and  Gerard).  It  is  best  to  reserve  it  for  those 
cases  in  which  the  history  or  examination  of  the  blood 
shows  that  the  patient  is  the  subject  of  malaria. 
Marfan  has  advocated  it  on  account  of  its  stimulating 
action  on  the  heart,  especially  in  children  :  the  hydro - 
chlorate  of  quinine  is  the  preparation  chiefly  used,  in 
doses  of  0-05  gramme  to  0-10  gramme  for  each  year  of 
age,  in  the  twenty-four  hours,  and  in  doses  of  0-50  to 
1  gramme  in  adults. 


TREATMENT  141 

Various  Modes  of  Treatment 

Bleeding. — Bleeding,  of  which  so  much  abuse  was 
made  in  former  times,  may  serve  as  one  of  the  agents 
for  combating  infection  (Pecker,  Grasset,  0.  Martin). 
It  may  be  employed  in  the  severe  forms  in  which  the 
patient  presents  marked  signs  of  intoxication ;  such 
as  a  very  pronounced  typhoid  state,  or  in  the  ataxo- 
adynamic  form ;  likewise  in  cases  in  which  the  patient 
has  a  severe  attack  with  a  feeble  reaction  and  com- 
paratively low  temperature. 

Lastly,  it  will  be  prudent  to  bleed  if  other  methods 
for  removing  toxins  are  not  sufficiently  rapid ;  when 
the  heart-sounds  become  more  and  more  muffied  and 
the  pulse  weak,  soft  and  irregular  with  a  high  number 
of  beats,  150,  200  or  300  grammes  of  blood  may  be 
withdrawn,  but  an  injection  of  artificial  serum  should 
be  made  at  the  same  time.  The  solution  employed  will 
be  the  so-called  normal  saline  solution  of  sodium 
chloride  at  7  per  1000  (Dastre,  Mayet,  Delbet,  Bosc 
and  Vedel).  Dieulafoy  adds  O'lO  gramme  of  benzoate 
of  caffeine  per  litre  of  serum  to  9-5  per  1000  of  sodium 
chloride,  and  injects  from  50  to  400  grammes.  The 
injection  may  be  made  into  the  muscle,  but  if  it  is  made 
after  the  bleeding,  or  if  rapid  effect  is  desired  (e.  g.  in 
a  case  of  alarming  collapse),  it  should  be  made  intra- 
venously and  very  slowly.  Injections  of  normal  saline 
raise  the  blood  pressure,  stimulate  the  nervous  and 
haematopoietic  centres,  and  facilitate  the  elimination 
of  toxins  by  provoking  abundant  diuresis,  frequent 
diarrhoea  and  sometimes  vomiting. 

Fixation  abscess. — This  old  method  of  treatment, 
which  has  been  employed  with  varying  success  for  the 
treatment  of  septicaemia,  consists  in  the  injection  of 
1  c.c.  of  oU  of  turpentine  beneath  the  skin  of  the  thigh 
on  its  outer  aspect.  It  is  said  to  cause  a  decided  fall 
in  the  temperature  and  improvement  of  the  patient's 
general  condition  if  it  results  in  the  formation  of  an 
abscess  (Rathe ry).  When  the  injection  does  not  cause 
an  abscess,  the  prognosis  as  a  rule  is  gloomy.    J.  Carles 


142    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

usually  keeps  this  method  for  septicsemic  forms  with 
severe  and  protracted  broncho-pneumonia,  and  for 
those  occasions  in  which  a  serious  inflammatory  or 
purulent  localisation  may  be  expected  owing  to  the 
organ  affected. 

Antiseptic  medication. — For  the  digestive  disturbance 
which  is  so  pronounced  a  feature  at  the  onset  of  typhoid 
fever,  hydrochloric  lemonade  may  be  of  service  in  doses 
of  2-4  grammes  per  litre. 

Purgatives  and  laxatives  should  not  be  employed 
either  in  the  adult  or  child,  except  in  the  course  of  the 
first  week.  At  the  onset  a  saline  purgative  may  be 
given,  e.  g.  15-20  grammes  of  sodium  sulphate  or 
magnesia  :  calomel,  whose  action  on  the  liver  is  well 
known,  may  be  given,  especially  to  children.  Dieulafoy 
employs  manna  in  doses  of  15-25  grammes  in  milk. 

After  the  first  week  every  purgative  or  laxative 
should  be  avoided,  as  they  are  capable  of  producing 
just  those  complications  which  we  endeavour  to  avoid, 
viz.  haemorrhage,  perforation  and  peritonitis.  If  their 
employment  does  not  always  have  such  grave  results, 
it  may  cause  rises  of  temperature.  Courtellemont  has 
fairly  often  seen  death  from  perforation,  especially  from 
the  twelfth  to  the  twentieth  day,  after  the  adminis- 
tration of  a  purgative.  The  following  course  of  events 
is  not  uncommon  :  the  taking  of  a  laxative  or  purga- 
tive, two  days  afterwards  haemorrhage,  and  two  or 
three  days  later  perforation  and  death. 

Among  other  drugs  employed,  the  most  usual  are 
beta-naphthol,  in  doses  of  2-50  grammes  in  the  twenty- 
four  hours  (Bouchard) ;  betol  (salicylate  of  naphthol) ; 
benzonaphthol,  3-4  grammes  in  6  or  8  doses  suspended 
in  milk ;  salol,  associated  or  not  with  salicylate  bf  bis- 
muth (Dujardin-Beaumetz) ;  lactic  acid  in  the  form  of 
lemonade  in  doses  of  15-25  grammes  daily  (Hayem) ; 
peroxide  of  magnesium  in  keratinised  capsules  of  0-30 
gramme,  two  capsules  to  be  taken  every  three  or  four 
hours  (Kirkpatrick) ;  camphorated  phenol  in  doses  of  ten 
drops  every  two  hours  ;  urotropine  (Chauffard,  Triboulet 
and  Levy),  which,  it   must    not    be    forgotten,  may 


TREATMENT  143 

cause  hsematuria  in  acute  infectious  diseases,  and 
especially  in  typhoid  fever  (Karkowski),  but,  by  reason 
of  its  elimination  by  the  bile  passages,  causes  a  biliary 
and  genito -urinary  antisepsis  simultaneously.  Iodine, 
as  the  freshly  prepared  tincture,  has  been  employed 
by  Raymond,  Arnozan  and  Carles. 

Diuretics. — We  have  already  insisted  on  the  necessity 
of  making  the  typhoid  patient  drink  a  large  quantity 
of  fluid,  so  as  to  provoke  diuresis,  and  elimination  of  all 
the  toxins  by  the  renal  channel. 

Injections  of  normal  saline  favour  diuresis.  It  is  the 
same  with  cold  sponging,  hatJis  and  liot  enemata.  These 
different  methods  will  suffice  in  most  cases.  It  may, 
however,  be  necessary  to  prescribe  lactose,  theobromine, 
digitalis  and  adrenalin,  which  have  a  diuretic  action, 
but  also  respond  to  other  indications. 

Tonics. — Alcohol  in  all  its  forms  (wine,  rum,  cognac, 
liqueurs)  is  a  good  tonic.  English  physicians  give  doses 
of  alcohol  which  we  regard  as  excessive,  sometimes 
more  than  a  litre  in  the  twenty -four  hours.  In  France 
an  average  of  80-100  grammes  of  alcohol  is  given. 
Frequent  use  is  made  of  wine,  chiefly  champagne,  which 
the  patients  tolerate  and  drink  readily,  especially  when 
it  is  iced. 

Caffeine  and  ether  respond  to  special  indications, 
which  we  mil  discuss  later. 

Drugs  for  combating  infection. — The  direct  employ- 
ment of  colloidal  substances  has  been  proposed,  e.  g. 
collargol,  electrargol,  lantol  (colloidal  rhodium),  colloidal 
gold  (Letulle).  Their  action  in  some  cases  has  ap- 
peared beneficial,  but  their  value  is  by  no  means 
proved.  Robin,  who  has  paid  special  attention  to  the 
study  of  electrargol  and  collargol,  concludes  that  they 
are  inefficacious  in  the  treatment  of  typhoid  fever. 

Treatment  of  Complications 

In  the  course  of  typhoid  fever  certain  normal  symp- 
toms may  become  exaggerated  and  constitute  an 
aggravation,  such  as  diarrhoea  when  it  becomes  pro- 


144    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

fuse  and  does  not  yield  to  treatment.  But  these  are 
mere  incidents.  The  real  complications  are  "  intes- 
tinal haemorrhage  and  perforation,  pulmonary  conges- 
tion and  pneumonia,  myocarditis  and  weakness  of  the 
heart,  nephritis,  and  every  result  of  the  lesions,  de- 
generations and  infections  peculiar  to  typhoid  fever 
of  a  severe  character  or  which  has  come  under  treatment 
late  "  (Merklen).  These  accidents  and  complications 
involve  special  indications  for  treatment,  which  we  will 
briefly  describe. 

Complications  Involving  the  Digestive 
System 

Diarrhoea. — Too  active  measures  should  not  be  taken 
against  the  diarrhoea.  To  check  it,  it  will  be  sufficient 
to  give  sterilised  milk  diluted  with  lime  water,  or  to 
lengthen  the  interval  between  the  feeds. — Lemonade 
with  lactic  acid  (10  grammes)  with  syrup  of  rhatany  or 
lemon,  benzo-naphthol,  salicylate  or  suhnitrate  of  bis- 
muth, absorptive  powders  such  as  prepared  chalk  and 
charcoal,  or  dermolol  (subgallate  of  bismuth)  may  be 
prescribed. 

Constipation,. — Avoid  laxatives  and  purgatives  after 
the  first  week.  Have  recourse  to  intestinal  lavage  or 
enemata.  A  daily  enema  of  boiled  water,  which  may 
be  given  cold  (when  it  does  not  cause  colic)  or  warm, 
is  usually  sufficient.  Emollient  enemata  (mallow,  or 
marsh  mallow  root)  have  been  recommended.  Oil  or 
glycerine  may  be  added  to  the  water.  When  the  con- 
stipation is  obstinate,  and  accompanied  by  abdominal 
pain  and  meteorism,  calomel  (10-25  centigrammes) 
should  be  given. 

Vomiting. — This  may  sometimes  be  due  to  too  large 
a  consumption  of  alcoholic  beverages,  and  their  diminu- 
tion or  suppression  will  be  enough  to  stop  the  vomiting. 
Iced  or  aerated  drinks,  and  cold  compresses  or  ice  on 
the  epigastrium  will  also  produce  a  good  result.  Hydro- 
chloric lemonade  (2-4  grammes  per  1000),  Riviere's 
potion,  ether  sprays,  inhalations  of  oxygen  and  menthol 


TREATMENT  145 

(in  three  or  four  doses  of  5  centigrammes  at  long 
intervals)  will  give  good  results.  Vomiting  is  fairly 
frequently  a  symptom  of  suprarenal  insufficiency,  as 
is  proved  by  the  efficacy  of  treatment  by  adrenalin 
(Khoury). 

Intestinal  hcemorrhage.  —  Absolute  rest  should  be 
ordered.  The  baths  must  be  stopped;  the  patient 
should  be  placed  in  the  dorsal  decubitus  with  an  ice- 
bag  on  the  abdomen ;  drinks  should  be  iced  and  in 
very  small  quantities,  consisting  of  champagne,  iced 
lemonade  with  eau  de  Rabel,  or  a  draught  containing 
water  130  grammes,  syrup  of  rhatany  30  grammes, 
eau  de  Rabel  2  grammes  (Dieulafoy),  to  be  given  in 
spoonfuls. 

Every  twenty-four  hours  the  patient  should  be  given 
3-4  grammes  of  calcium  chloride,  with  or  without  large 
hot  -enemata  (Mathieu). 

If  the  haemorrhage  is  profuse  and  obstinate,  all  food 
by  mouth  should  be  absolutely  stopped,  and  an  injec- 
tion of  normal  saline  (600  c.c.-1800  c.c.)  should  be  given 
at  a  temperature  of  102-2  or  104°  F. 

Injection  of  gelatinised  serum  has  given  good  results. 
The  haemorrhage  may  be  so  profuse  that  the  patient 
faints.  In  that  case  the  head  should  be  placed  as  low 
as  possible,  an  injection  of  ergotinin  should  be  given, 
and  then  as  soon  as  possible  an  injection  of  horse  serum 
or  normal  saline  solution.  The  patient  should  be  made 
warm.  Injections  of  camphorated  oil  and  ether  are 
sometimes  of  service. 

Intestinal  perforation.  Peritonitis.  —  "Every  un- 
doubted perforation  of  the  intestine  demands  surgical 
intervention  "  (Michaux).  This  intervention  should 
be  done  as  soon  as  possible.  While  waiting  for"  the 
surgeon,  the  patient  should  be  kept  absolutely  still  in 
bed,  all  fluid  should  be  stopped.  An  intramuscular 
injection  of  nucleinate  of  soda  should  be  given  (Miculicz, 
Chantemesse,  Tuffier),  which  has  the  property  of 
causing  a  leucocytosis  which  increases  the  patient's 
resistance.  If  necessary,  injections  of  ether,  cam- 
phorated oil  or  caffeine  should  be  given. 


146    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  physician's  role  is  limited  to  this.  Surgical 
intervention  alone  can  save  the  patient. 

Cardiac  complications. — In  moderate  attacks  the 
strength  of  the  heart  is,  as  a  rule,  sufficiently  main- 
tained by  the  diet,  meat  juice,  etc.,  containing  alcohol 
and  wine.  In  more  severe  attacks  ice  should  be  put 
on  the  prsecordial  region,  the  baths  should  be  given 
hotter  and  with  extreme  care,  at  longer  intervals  or 
stopped  altogether.  Repeated  injections  should  be 
given  of  camphorated  oil,  ether,  sparteine,  sulphate  of 
strychnine,  and  normal  saline  solution  containing 
adrenalin.  Lastly,  since  the  role  of  the  suprarenals  has 
been  better  understood,  numerous  accidents  due  to 
suprarenal  insufficiency  have  been  reported  (E.  Sergent, 
Hutinel).  The  patient  is  given  adrenalin  subcutane- 
ously,  either  in  the  form  of  l-J  c.c.  of  a  1  in  1000  solu- 
tion, or,  better  still,  as  adrenalin  in  a  saline  solution 
obtained  by  adding  1  c.c.  of  1  in  1000  solution  of 
adrenalin  (^.  e.  1  milligramme  of  adrenalin)  to  250- 
500  c.c.  of  normal  saline  solution  (Josue). 

The  total  extract  of  the  suprarenals  taken  internally 
in  daily  doses  of  0-20  to  0-40,  with  or  without  injection 
of  normal  saline  solution  with  adrenalin,  glucose  or 
novocain,  is  very  successful  in  the  severest  cases  with 
threatening  collapse,  or  at  the  time  of  convalescence 
(Rathery,  Josue,  Sabrazes). 

In  some  cases  faradisation  of  the  heart  has  been 
employed  with  success,  the  positive  electrode  being 
placed  on  the  pneumo -gastric  and  the  cathode  over  the 
heart. 

Pulmonary  complications. — Pulmonary  complications 
are  far  from  being  a  contra -indication  for  baths.  At 
most  they  may  sometimes  have  to  be  given  a  little 
hotter.  It  is  most  important  for  the  typhoid  patient 
to  change  frequently  his  position  in  bed.  This  change 
will  prevent  or  restrict  any  pulmonary  complications. 
If  they  do  occur,  dry  or  ivet  cupping  will  be  the  best 
treatment.     Blisters  should  never  be  applied. 

In  cases  of  diffuse  bronchitis  or  broncho-pneumonia, 
injections  of  emetine  hydrochloride  for  four  consecutive 


TREATMENT  147 

days,  in  doses  of  4,  6,  7  or  8  centigrammes,  have  given 
the  most  excellent  results. 

Serous  or  hcemorrhagic  "pleurisy  is  generally  absorbed 
and  very  rarely  requires  thoracocentesis.  As  for  puru- 
lent pleurisy,  if  thoracocentesis  is  not  sufficient,  it  may 
be  necessary  to  perform  thoracotomy.  If  the  laryn- 
geal symptoms  do  not  yield  to  moist,  hot  compresses 
or  inhalations,  in  severe  cases  with  suffocative  attacks 
it  will  be  necessary  to  resort  to  tracheotomy. 

Nervous  complications. — Hot  or  cold  baths  exercise 
a  remarkably  sedative  action  on  most  nervous  symp- 
toms. These  may,  however,  by  their  intensity  and 
obstinacy,  require  special  treatment. 

Headache  is  usually  diminished  or  removed  by 
affusions,  or  cold  or  iced  compresses,  but  sometimes 
proves  more  dbstinate.  Lumbar  puncture  not  only 
permits  of  examination  of  the  fluid  withdrawn,  but 
causes  almost  immediate  relief.  A  single  puncture  is 
often  sufficient. 

Urinary  complications. — When  the  patient  passes 
little  urine,  dry  cups  should  be  placed  over  the  kidneys. 
But  the  best  diuretics  are  always  the  cold  bath,  milk 
and  lactose.  Diuretic  drugs  have  generally  little  effect. 
If  the  patient  has  retention,  he  must  be  catheterised, 
with  the  aseptic  precautions  described  above. 

In  cases  of  bacteriuria  the  bladder  should  be  washed 
out  with  a  weak  solution  of  permanganate  of  potash. 

Cutaneous  complications. — In  dealing  with  the  nursing 
of  the  typhoid  patient  we  have  laid  special  stress  on 
the  skin  lesions,  which  can  be  prevented  by  asepsis. 
If  a  bedsore  develops,  in  spite  of  all  the  precautions 
taken,  it  should  be  disinfected  carefully  and  closely 
watched,  for  it  may  be  the  starting-point  of  secondary 
septic  semia. 

In  addition  to  the  measures  indicated  above,  we  may 
use  dressings  of  salol,  aristol,  dermatol  or  Vincent's 
antiseptic  powder  (boracic  powder  100  grammes,  fresh 
hypochlorite  of  calcium  10  grammes). 

Abscesses  and  phlegmons,  especially  in  the  parotid, 
should  be  incised  without  delay. 


148    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Specific?  Treatment 

Serum  therapy.  Vaccine  therapy. — A  successful 
specific  treatment  for  typhoid  and  paratyphoid  fevers 
has  long  been  sought  for.  Two  methods  have  been 
proposed  :    Serum  therapy  and  Vaccine  therapy. 

Serum  therapy. — Chantemesse  has  employed  a  serum 
derived  from  horses  which  have  undergone  a  long 
immunisation.  These  horses  were  given  soluble  typhoid 
toxin  exclusively.  At  present,  injections  of  this  toxin 
are  sometimes  given  and  sometimes '  intravenous  in- 
jections of  living  bacilli,  according  to  the  method  of 
Rodet  and  Lagriffoul. 

Soluble  toxin  is  obtained  by  cultivating  very  virulent 
typhoid  bacilli  on  a  special  medium  containing  de- 
fibrinated  blood  and  spleen  and  bone-marrow  broth 
(Chantemesse).  In  a  week's  time  the  culture  is  heated 
to  +.55°  C,  centrifugalised  and  decanted. 

The  most  active  serum  is  obtained  after  the  last 
injection  given  to  the  horse.  But  the  activity  of  this 
serum  varies. 

At  first  Chantemesse  injected  the  patient  with  5- 
15  c.c.  of  his  serum,  but  later  he  injected  extremely 
small  doses,  consisting  of  only  a  few  drops. 

According  to  Milhit,  the  serum  stimulates  the  organs 
producing  opsonins,  the  secretion  of  which  becomes 
very  intense.  At  the  same  time  a  high  leucocytosis 
appears  (as  much  as  18,000  white  cells  per  cubic  milli- 
metre), with  polymorphonucleosis  and  eosinophilia 
(Balthazard). 

According  to  Chantemesse,  the  worse  the  patient  is, 
the  smaller  should  be  the  doses  of  serum  injected.  He 
particularly  advises  that  cold  bath  treatment  should 
not  be  neglected,  but  continued  with  the  serum  treat- 
ment. From  statistics  published  by  him  and  by  Josias 
and  Brunon,  it  appears  that  the  mortality  in  cases 
treated  by  this  method  has  been  4-3  per  cent. 

A  large  number  of  serums  has  been  prepared  by 
injecting  animals  with  filtered  cultures  (Shaw,  Meyer, 
Bergell.    Aronson,    Richardson,    etc.),    or   extracts   of 


TREATMENT  149 

bacilli  ground  in  liquid  air  (Macfadyen).  Besredka 
inoculated  an  animal  first  mth  dead  and  then  with 
living  bacilli.  Jez  has  used  the  blood-forming  organs 
(bone -marrow,  spleen,  thymus),  in  a  crushed  and  filtered 
state,  from  animals  which  had  been  strongly  immunised 
against  the  typhoid  bacillus.  H.  Vincent  prepared  a 
typhoid  serum  by  injecting  a  horse  with  very  virulent 
and  highly  toxic  cultures  of  strains  of  bacilli  cultivated 
in  a  collodion  bag  within  the  peritoneum  of  a  guinea- 

Rodet  and  Lagriffoul  inject  living  cultures  of  bacilli 
into  the  veins  of  sheep  and  horses.  According  to  them, 
the  most  active  serums  are  derived  from  animals  who 
have  received  only  a  small  number  of  injections  and 
minimal  doses.  Serums  derived  from  animals  who  have 
been  given  too  large  and  numerous  doses  have  an 
injurious  effect,  and  even  show  an  action  which  favours 
the  experimental  toxi-infection.  Rodet  thinks  that  the 
treatment  by  this  serum  should  only  be  undertaken 
when  typhoid  fever  has  been  diagnosed  by  a  blood- 
culture  or  serum  test,  without  any  previous  or  super- 
added infection.  Myocarditis  and  intestinal  haemor- 
rhage form  absolute,  contra-indications.  The  serum 
should  be  given  subcutaneously,  at  an  early  date,  i.  e. 
at  the  latest  at  the  tenth  to  the  eleventh  day  of  the 
febrile  period ;  15-20  c.c.  are  given  at  one  or  two 
injections,  with  an  interval  of  two  days. 

According  to  Rodet,  in  thirty -six  to  forty -eight  hours 
a  fall  of  temperature,  improvement  of  the  general  con- 
dition, and,  in  spite  of  the  high  temperature,  a  marked 
sense  of  well-being  are  to  be  observed.  In  patients 
who  have  not  had  the  bath  treatment  there  is  a  verit- 
able polyuria,  which  precedes  apyrexia  by  several  days. 
In  several  cases  the  disease  is  shortened.  The  writer 
recognises  that  "  the  result  depends  on  the  quality  of 
the  serum,  for  it  is  difficult  to  make  the  horses  produce 
a  serum  whose  value  is  constant." 

Vaccine  therapy  or  bacterial  therapy. — For  the  first 
time,  in  1892,  Frsenkel  treated  fifty -seven  patients  by 
injecting  them  with  cultures  of  typhoid  bacilli  which 


150    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

had  been  heated  to  63°  C.  (in  doses  of  0-5  c.c.-2  c.c). 
He  had  five  deaths,  or  a  mortality  of  8-7  per  cent. 

Since  then  numerous  authors  have  employed  vaccine 
treatment  by  various  methods,  in  England  (A.  E. 
Wright),  in  the  United  States  (Petrovitch),  in  Italy,  etc. 

The  vaccine  used  for  this  treatment  may  be  divided 
into  three  classes — 

1.  Vaccines  of  living  bacilli. 

2.  Vaccines  of  bacilli  killed  by  heat. 

3.  Vaccines  of  bacilli  killed  by  ether :  Vincent's 
bacillary  vaccine  and  autolysat. 

1.  Vaccines  of  living  hacilli.  Living  sensitised  vaccine 
(Besredka). — This  vaccine,  when  given  in  four  injec- 
tions in  increasing  doses,  one  every  three  days  (in  doses 
of  from  one  to  four  thousand  millions),  produces  locally 
pruritus,  more  or  less  marked  erythema,  with  decided 
rise  of  temperature  and  improvement  of  the  general 
condition  in  twenty-four  to  forty-eight  hours,  with 
marked  diuresis  and  sometimes  actual  polyuria.  Some 
days  later  there  is  a  progressive  fall  of  the  tempera-= 
ture.  Ardin-Deltheil,  Negre  and  Raynaud  have  em- 
ployed it  in  thirty-seven  cases  in  patients  who  were 
having  the  ordinary  general  treatment.  They  had  no 
deaths,  and  only  two  of  their  patients  had  relapses. 

Sable  thinks  that  Besredka 's  vaccine  has  in  some 
cases  produced  an  undoubted  action  on  the  temperature 
and  general  condition.  Delearde  and  Leborgne,  who 
have  employed  it  in  the  typhoid  fever  of  children,  do 
not  think  that  the  old  methods  of  treatment  should 
be  given  up  at  present,  e.  g.  cold  baths,  ice  to  the 
prsscordial  regions  and  plenty  of  fluids. 

Faucher  and  Lafosse  have  had  rather  bad  results 
with  this  vaccine  in  military  patients. 

2.  Bacilli  killed  by  heat. — Josue  and  Belloir  have 
made  use  of  autovaccines,  i.  e.  vaccines  obtained  from 
cultures  of  bacilli  derived  from  the  patient  himself  and 
heated  to  56°  C.  for  six  hours.  They  give  three  injec- 
tions of  200,000,000  bacilli  at  twelve  hours'  interval. 
They  say  that  they  have  obtained  good  results,  without 
any  complications. 


TREATMENT  151 

The  other  vaccines  in  use  are  mostly  he tero -vaccines. 

Among  these  is  the  hacillary  vaccine  sterih'sed  by 
heating  at  56°  C,  used  in  England,  the  United  States, 
etc.,  as  well  as  in  France.  The  vaccine  to  be  employed 
contains,  on  the  average,  100,000,000  bacilli  per  c.c. 

The  injection  is  made  in  the  deltoid  region.  At  the 
onset  of  the  disease,  in  severe  cases,  small  doses  must 
be  given.  The  first  injection  is  thirty,  forty,  or  fifty 
million  bacilli ;  the  second,  given  five  days  later,  is  half 
the  first,  and  the  third  and  fourth,  given  at  the  same 
intervals,  are  only  ten  millions. 

The  temperature  curve  descends  regularly  by  lysis 
after  treatment.  D'Oelnitz,  in  children,  obtained 
similar  results,  with  leucocytosis  and  definite  increase 
in  the  size  of  the  spleen.  Castaigne  has  published  a 
series  of  charts  showing  rises  of  temperature  after  each 
injection  of  vaccine.  These  rises  were  followed  by  a 
pronounced  fall  the  next  day. 

Generally  speaking,  heated  bacillary  vaccines  em- 
ployed in  large  doses  have  a  violent  action,  which 
cannot  be  measured  or  foreseen.  The  reaction  of  the 
temperature  in  an  upward  or  downward  direction  is 
often  very  marked.  A  certain  number  of  writers  are 
guarded  as  to  their  use,  as  it  may  be  accompanied  by 
shivering,  collapse,  icterus  and  even  rupture  of  the 
spleen.  But  such  accidents  are  the  result  of  too  large 
doses. 

In  order  to  avoid  subcutaneous  injections,  Courmont 
and  Rochaix  have  suggested  giving  patients  two  rectal 
injections  daily  until  convalescence,  containing  100  c.c. 
of  a  culture  of  typhoid  bacilli  killed  at  -f  53°  C. 

3.  Polyvalent  bacillary  vaccine  sterilised  by  ether. 
Autolysat. — H.  Vincent  has  shown  that  the  preventive 
vaccine  tends  to  check  the  disease  if  it  is  given  ^at  the 
onset  of  the  incubation  period,  when  the  exact  moment 
at  which  the  ingestion  of  typhoid  bacilli  took  place  can 
be  determined  (laboratory  cases).  It  has  also  been 
found  that  individuals  vaccinated  during  the  incuba- 
tion period  have  had  mild,  abortive  or  shortened  attacks 
of  typhoid  fever. 


152    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Generally  speaking,  considerable  prudence  is  required 
in  the  employment  of  vaccine  therapy,  the  object  of 
which  is  to  rouse  and  stimulate  the  latent  defensive 
forces  of  the  infected  organism  and  to  provoke  the 
secretion  of  an  excess  of  antibodies  (amboceptor, 
bacteriolysis,  etc.). 

The  indications  and  contra -indications  for  vaccine 
treatment  by  the  ether  vaccine  may  be  resumed  as 
follows — 

1 .  A  patient  with  a  severe  attack,  and  especially  one 
of  long-standing,  should  not  be  given  vaccine  treat- 
ment. He  cannot  undergo  with  impunity  the  shock 
necessarily  induced  by  the  inoculation  of  an  additional 
quantity  of  antigen.  It  is,  therefore,  at  the  beginning 
or  in  the  first  two  weeks  of  the  disease — when  the 
patient  still  possesses  a  store  of  defensive  energy  and 
is  not  too  deeply  intoxicated — that  vaccine  treatment 
can  be  employed  to  best  advantage. 

2.  Too  high  doses  of  antigen  may  be  dangerous.  It 
is  evidently  just  the  same  with  anti-typhoid  vaccine 
as  with  any  very  active  drug.  But,  on  the  other  hand, 
too  small  doses,  whether  repeated  or  not,  remain 
without  effect. 

Experience  has  shown  that  extracts  or  autolysats  of 
living  bacilli,  afterwards  sterilised  by  ether,  produce 
in  the  adult  very  superior  results  to  those  given  by  the 
bacillary  vaccine  properly  so-called.  The  latter,  on 
the  other  hand,  has  yielded  remarkable  results  in  the 
chUd  (E.  Weill). 

Bacillary  vaccines  and  specific  autolysats  sterilised 
by  ether  are  prepared  for  typhoid  fever,  and  for 
paratyphoid  A  and  B  fevers. 

Before  undertaking  vaccine  treatment  one  should 
make  sure  of  the  diagnosis  by  an  early  cultivation  of 
the  blood.  In  the  absence  of  a  blood-culture,  investiga- 
tion of  the  spleno -reaction,  carried  out  with  the  autolysat 
(it  is  very  inconstant  with  the  bacillary  vaccine),  may 
help  to  settle  the  diagnosis. 

The  first  dose  of  antigen  to  be  injected  in  an  adult 
is  1  c.c. 


TREATMENT  153 

The  inoculation  is  made  subcutaneously  in  the 
clavicular  region  (and  not  behind,  as  in  preventive 
inoculation),  because  the  patient  is  in  bed.  The  in- 
jection should  be  made  preferably  in  the  morning. 
If  the  vaccine  causes  an  abnormal  rise  of  temperature 
or  pain,  0-50  gramme  of  aspirin  should  be  given  an 
hour  after  injection,  except  in  cases  of  intolerance  or 
special  contraindication . 

If  the  temperature  does  not  fall  thirty-six  or  forty- 
eight  hours  later  in  an  appreciable  degree,  the  injection 
may  be  repeated,  when  the  spleen,  which  had  become 
enlarged,  has  returned  to  its  former  size.  This  reduc- 
tion in  size  usually  occurs  two  or  three  days  later.  The 
dose  on  the  second  occasion  is  1-2  c.c.  However,  if 
a  fall  of  temperature  occurs,  one  must  avoid  disturbing 
this  salutary  defervescence  by  a  fresh  injection  of 
vaccine.  Such  an  injection  wOuld  result  in  arresting 
the  decline  of  the  fever,  and  in  causing  a  sort  of  negative 
phase  by  neutralisation  of  the  already  existing  ambo- 
ceptors. Another  injection  should  only  be  made  when 
the  temperature  has  returned  to  its  former  level,  or 
nearly  so. 

Very  marked  enlargement  of  the  spleen  constitutes 
a  contra -indication  for  the  use  of  vaccine  treatment 
(Vincent). 

In  patients  treated  by  vaccine  therapy  there  is  no 
need  to  modify  or  suspend  the  cold  bath  treatment. 

The  injection  of  vaccine  causes,  or  may  cause,  a 
diminution  of  the  toxi-infective  symptoms,  and,  two  or 
three  days  later,  a  fall  of  the  patient's  temperature. 
Convalescence  may  occur  in  two,  three  or  four  days. 
Unfortunately,  this  improvement  in  the  symptoms  is 
by  no  means  constant. 

Relapses  seem  rarer  than  in  patients  who  have  not 
been  treated  by  vaccine. 

Variot,  Grenet  and  Dumont  have  treated  sixteen 
patients  with  Vincent's  polyvalent  vaccine.  Only  one 
died,  and  he  had  been  injected  at  the  time  of  a  per- 
foration. Four  times  defervescence  was  obtained  in 
twelve  days.     In  one  patient,  in  the  course  of  a  severe 


154    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

relapse  with  meningeal  symptoms  and  infective 
erythemata,  the  temperature  fell  in  forty-eight  hours 
after  an  injection  of  1  c.c.  of  vaccine.  In  the  other  case 
the  duration  was  shortened,  the  general  state  improved, 
and  the  pulse  rate  lessened. 

In  thirty -four  out  of  fifty  cases  treated  by  Thiroloix 
the  disease  was  made  milder  and  shorter. 

E.  Weill  treated  fourteen  children  by  the  preventive 
bacillary  vaccine,  sterilised  by  ether.  These  cases  of 
tj^phoid  fever,  which  were  of  moderate  intensity,  first 
came  under  treatment  from  the  third  to  the  tenth  day. 

Weill  injected  children  above  five  years  of  age  daily 
v.dth  J  c.c,  J  c.c.  and  1  c.c. ;  then,  after  missing  one 
day,  with  15  c.c.  and  2  c.c.  Below  that  age  he 
began  with  J  c.c,  to  end  with  1  c.c  or  1-5  c.c 

Recovery  was  obtained  in  one  or  two  weeks,  in  one 
case  only  in  twenty  days.  There  was  no  death,  no 
relapse  and  no  complication. 

Lenglet  treated  his  paratyphoid  A  cases  with  vaccine 
therapy.  Although  it  did  not  always  reduce  the  dura- 
tion of  the  height  of  the  disease,  the  vaccine  seemed  to 
prevent  any  relapse.  Doubtless  for  the  same  thera- 
peutical reason  complications  were  exceptional. 

Rathery  and  Michel  treated  with  Vincent's  autolysat 
para.  B  147  cases  of  paratyphoid  fever  B,  in  which  the 
diagnosis  was  confirmed  by  laboratory  examination. 
They  had  only  five  deaths,  or  a  mortality  of  3'40  per 
cent.  They  regard  vaccine  therapy  as  a  useful  adjunct 
to  treatment,  a  very  definite  improvement  of  the 
general  state  having  followed  the  injections  almost 
invariably.  In  a  fairly  large  number  of  cases  the 
disease  seems  curtailed,  and  the  symptoms  of  a  hurried 
crisis  occur  (fall  of  temperature,  polyuria,  etc.). 

In  some  subjects  vaccine  therapy  seems  to  produce 
no  perceptible  effect,  but  even  in  these  cases  it  seems 
that  the  method  of  treatment  does  not  fail  to  exercise 
a  beneficial  influence  on  the  course  of  the  disease. 

P.  Emile  Weill  has  treated  some  cases  of  obstinate 
typhoid  osteomyelitis  by  injections  of  H.  Vincent's 
ether  vaccine,  with  excellent  results. 


TREATMENT  155 

The  treatment  consists  in  two  injections  weekly  until 
recovery  :  the  doses  of  the  first  injections  are  respect- 
ively J  c.c,  J  c.c,  I  c.c.  and  then  1  c.c,  which  dose  is 
then  continued  without  further  increase.  When  em- 
ployed in  this  sort  of  preventive  manner,  vaccine 
therapy  will  yield  remarkable  results,  considering  the 
slowness  with  which  the  typhoid  bone  lesions  form. 

In  osteomyelitis  of  paratyphoid  origin,  Weil  thinks 
it  would  be  advisable  to  employ  the  same  method,  using 
paratyphoid  bacilli. 


SECOND   PART 

EPIDEMIOLOGY  AND  PROPHYLAXIS  OF  TYPHOID 
FEVER   AND   PARATYPHOID   FEVERS 


CHAPTER  VI 

EPIDEMIOLOGY   OF   TYPHOID    FEVER — FREQUENCY 
OF   THE    DISEASE 

The  historical  and  geographical  study  of  the  epidemic 
or  endemic  manifestations  of  typhoid  fever  bears 
witness  to  the  extent  and  gravity  of  this  important 
disease.  No  country  is  protected  from  its  attacks. 
It  is  prevalent  in  villages  as  in  large  towns,  in  armies 
in  time  of  peace  and  still  more  so  in  time  of  war,  when 
it  causes  a  considerable  number  of  deaths. 

In  France,  in  the  course  of  twenty  or  twenty-five 
years,  typhoid  fever  carries  off  a  number  of  inhabitants 
equal  to  that  of  a  large  town  such  as  Toulouse.  From 
1906  to  1 9 10  (both  inclusive)  The  Sanitary  Statistics 
of  France,  published  by  the  French  Home  Office, 
registered  22,463  deaths  due  to  this  infectious  disease. 
During  the  same  period  of  four  years  Paris  alone  had 
1251  deaths  from  tj^hoid  fever. 

From  1891-1900  the  average  proportion  of  deaths 
from  typhoid  fever  per  100,000  inhabitants  in  some 
of  the  towns  of  France  has  been  as  follows — 

Havre 115      Rheims 30 

Rouen 61       Lyons 24 

Marseilles 5G       Bordeaux 24 

Xantes 45      Paris 21 

Toulouse 32      Lille 11 

15G 


EPIDEMIOLOGY 


157 


The  deaths  from  typhoid  fever  in  France  from 
1013  to  1915  inclusive,  in  towns  of  30,000  inhabitants 
and  more,  have  been  as  follows — 

1886-1890 0-54  per  thousand 

1891-1895 0-34 

1896-1900 0-30 

1901-1905 0-20 

1906-1910 .  0-18 

1911 018 

1912 013 

1913 014 

From  1896-1900  the  typhoid  mortality  in  the 
principal  European  countries  reached  the  following 
figures  per  100,000  inhabitants — 

Italy 49-7 

Hungary 34-4 

France 27-6 

Belgium 25-8 

Austria 24-6 

Ireland      .      .      .      .      .  20-7 

England 17-5 

More  recently,  the  comparative  mortality  from 
typhoid  fever  in  various  European  countries  per 
100,000  inhabitants  has  been  as  follows — 


Sweden 

.      .      15 

Denmark  . 

.      .      IM 

Germany  . 

.      .      10-3 

Netherlands    . 

.      .      10-2 

Switzerland     . 

.      .        8-4 

Norway 

.      .        7-5 

Tears 

France 

Germany 

England 

Belgium 

Spain 

Italy 

Switzer- 
land 

Nether- 
lands 

1906 

14 

5 

9 

12 

47 

28 

4 

1907 

15 

4 

6 

11 

41 

25 

5 

1908 

12 

5 

7 

11 

34 

27 

3 

6 

1909 

10 

4 

6 

9 

27 

28 

3 

5 

1910 

8 

26 

4 

1911 

^ 

27-5 

1912 

22 

Spain,  Russia,  Italy,  France,  Belgium  and  Roumania 
are  among  the  countries  which  suffer  most  from  typhoid 
fever. 

The  etiological  conditions  which  cause  the  outbreak 
of  the  disease  are  indeed  common  to  the  soldier  and 


158    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

the  civilian.  The  special  susceptibility  of  the  soldier 
certainly  helps  to  explain  the  remarkable  frequency 
with  which  he  is  affected. 

The  following  table  shows  the  respective  percentages 
of  cases  due  to  this  disease  in  the  principal  armies  in 
time  of  peace. 


Typhoid  Fever  in  Various  Armies 
Incidence  per  1000  men 


Armies 

1903 

1904 

1905 

1906 

1907 

ATerage  for 
the  5  Tears 

French 

5-10 

5-30 

3-70 

4-53 

3-74 

4-49 

German 

0-95 

0-79 

0-77 

0-51 

0-41 

0-68 

English 

0-80 

0--80 

0-60 

0-60 

0-70 

0-70 

Austrian 

1-60 

1-60 

2-10 

2-0 

310 

1-88 

Bavarian 

•0-47 

0-22 

0-93 

0-11 

0-17 

0-38 

Belgian 

1-89 

3-10 

1-35 

0-82 

0-86 

1-60 

Spanish 

2-60 

4-82 

3-68 

4-72 

2-87 

3-73 

Italian 

4-921 

Roumanian 

4-80 

4-08 

6-90 

5-33 

3-57 

4-73 

Russian 

5-30 

3-80 

5-10 

5-60 

5-50 

5-06 

United  States 

514 

4-77 

3-39 

6-15 

3-87 

4-66 

It  is  important  to  note  that  the  incidence  and 
mortality  of  typhoid  fever  in  the  French  army  are 
diminishing  appreciably  and,  one  may  say,  every  year, 
thanks  to  the  careful  hygienic  measures  adopted. 
The  institution  of  antityphoid  vaccination  began  to 
reduce  the  incidence  of  this  disease  commencing  with 
the  year  1913,  It  is  found,  however,  that  in  the 
distribution  of  cases  throughout  the  country,  there 
is  a  regular  predominance  of  typhoid  fever  in  the  army 
corps  in  the  south  and  south-west  of  France,  viz.  the 
XVth  at  Marseilles,  the  XVIth  at  Montpellier,  and 
the  XVIIth  at  Toulouse,  as  well  as  among  the  troops 
stationed  in  the  west  of  France,  e.  g.  Xth  Corps 
(Rennes),  Xlth  Corps  (Nantes).^ 

1  From  1900-1903  (both  inclusive). 

-  In  the  French  army,  Algeria,  and  Tunis,  by  their  high  incidence 
;f  typhoid  fever,  raise  th.i    eneral  percentage  incidence. 


EPIDEMIOLOGY 


159 


In  these  same  regions  the  civil  population  also  pays 
a  high  toll  to  the  same  disease,  as  Brouardel  had 
observed  long  ago.  Owing  to  the  close  parallelism 
existing  between  the  diseases  of  the  civil  population 
and  those  of  the  army,  Spain,  Roumania,  Italy,  France, 


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Typhoid  Fever  in  War  Time 

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160    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


a  Medical  Officer  of  the  American  army,  has  rightly 
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in  time  of  war."     Thanks,  however,  to  the  hygienic 


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measures  adopted,  modem  wars  are  far  from  showing 
the  appalling  incidence  of  the  wars  of  bygone  times. 

The  War  of  Secession  {June  I,  ISQl- June  30,  1866) 
put  in  the  field  431,237  men,  who  showed  75,368  cases 
of  typhoid  fever,  or   175  cases  per  1000,  and  27,056 


EPIDEMIOLOGY  161 

deaths,  or  57-78  deaths  per  1000.  Out  of  1000  deaths 
due  to  all  causes,  209  were  caused  by  typhoid  fever. 
Even  these  figures  do  not  include  the  cases  of  typho- 
malarial  fever,  i.e.  the  association  of  typhoid  fever 
and  malaria. 

During  the  Franco-German  War  of  1870,  the  German 
army,  whose  effectives  were  815,000  men,  had  73,396 
cases  (80-3  per  1000),  and  6965  deaths  due  to  typhoid 
fever. 

The  Turco-Russian  War  of  1877-1878  furnished 
another  proof  of  the  intensity  of  typhoid  infection 
among  troops  in  the  field. 

The  Russian  army  of  the  Danube,  comprising 
529,000  men,  had  25,000  cases  of  typhoid  fever  (not  in- 
cluding the  cases  of  "  undetermined  typhoid  diseases  "), 
or  42  cases  per  1000,  with  7800  deaths,  or  12  deaths 
per  1000,  whereas  this  army  lost  in  battle  only  4955 
men. 

The  army  of  the  Caucasus,  which  suffered  most, 
had  24,473  cases,  or  99  per  1000,  and  8900  deaths,  or 
36  deaths  per  1000,  as  compared  with  only  1975  who 
were  killed  by  the  enemy. 

We  have  here  an  example  of  the  extreme  gravity 
of  typhoid  fever  as  well  as  of  its  frequency  in  the  com- 
batant soldier.     Of  100  typhoid  cases,  36  succumbed. 

During  the  campaign  in  Bosnia-Herzegovina,  out  of 
2085  deaths  due  to  various  diseases,  944  were  caused 
by  typhoid  fever. 

The  Tunis  Expedition  in  1881,  and  the  South  Oran 
Expedition  in  the  same  year,  offered  numerous  examples 
of  the  extreme  gravity  of  typhoid.  The  army  of 
20,000  men  sent  to  Tunis  had  4200  cases  (one  case 
among  five  men)  and  1039  deaths  (more  than  one 
death  in  twenty).  The  Innocent!  Column  (21,000  men) 
sent  into  South  Oran  had  1400  cases  of  typhoid  fever 
and  425  deaths. 

The  small  French  Column  which  took  part  in  the 
Allies'  Expedition  to  China  had  633  cases  and  100 
deaths. 

In  the   War  ivitli  Spain  the  American  troops,  con- 


162    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

sisting  of  a  force  of  107,937  inen,  suffered  severely 
from  typhoid  fever.  The  average  proportion  of  cases 
was  192  per  1000.     There  were  nearly  3000  deaths. 

The  first  division  of  the  first  corps,  with  a  force 
of  11,339  men,  during  its  stay  at  Chickamauga  Camp, 
and  after  leaving  the  Camp,  yielded  a  total  of  1921 
cases. 

The  second  division  of  the  same  corps  (11,357  men) 
had  2172  cases. 

The  third  division,  which  suffered  most,  out  of  a 
force  of  10,329  men,  had  2726  cases,  a  proportion  of 
263-91  cases  pel-  1000,  or  more  than  one  case  in  every 
four  men,  with  a  mortality  of  16-36  per  1000. 

To  sum  up.  The  first,  second  and  third  divisions 
of  the  First  Corps,  out  of  a  force  of  33,025  men,  had 
6819  men  in  hospital  for  typhoid  fever,  with  471 
deaths  due  to  this  cause. 

In  the  Transvaal  War  typhoid  fever  (enteric  fever) 
was  far  and  away  the  predominant  disease  in  the 
English  army,  of  which  the  average  strength  was 
265,000  men." 

Out  of  22,450  deaths  from  disease,  typhoid  fever 
caused  7991. 

The  number  of  men  killed  by  the  enemy  was  hardly 
greater — 8590.  During  the  Siege  of  Ladysmith  the 
average  number  of  deaths  from  typhoid  fever  was 
somt^ times  10  per  day. 

In  the  German  Expedition  against  the  Herreros 
there  were  1277  cases  and  140  deaths.  In  the  period 
1905-1907,  out  of  a  force  of  18,116  men  there  were 
3146  cases  of  typhoid  fever  (Kutscher). 

The  Busso-Japanese  War  offers  a  happy  exception 
to  the  observations  made  in  other  wars. 

The  explanation  of  this  will  be  given  later.  The 
Russian  army  had  21,309  cases,  and  the  Japanese 
army  only  5474  cases  of  typhoid  fever.  The  disease 
rapidly  increased  after  August  1904,  and  reached  its 
maximum  in  November. 

We  may  remark  that  the  collection  of  statistics  given  , 
above  really  includes  under  the  same  heading  para- 


EPIDEMIOLOGY  163 

typhoid  fever,  the  nosological  isolation  of  which  is  of 
more  recent  date. 

The  War  of  1914-1916  has  furnished  a  new  proof 
of  the  great  importance  of  typhoid  fever  in  armies 
on  active  service.  During  the  first  months  of  this 
war,  although  the  season  was  remarkably  favourable 
for  the  outbreak  of  typhoid  fever,  in  spite,  also,  of  the 
terrible  fatigue  to  which  our  soldiers  were  subjected, 
typhoid  fever  proved  to  be  extremely  rare.  This 
remarkable  result  must  be  attributed  to  the  fact  that 
these  young  troops,  who  were  made  up  of  contingents 
coming  from  the  interior,  Algeria,  Tunis  and  Morocco, 
were  in  very  great  part  immunised  by  vaccination. 

Strategic  necessities,  as  well  ^as  the  losses  sustained 
in  the  open  field  and  in  the  trenches,  brought,  in  suc- 
cessive batches,  into  the  war  zone  large  quantities  of 
fresh  troops  who  were  composed,  especially  at  first, 
of  men  whom  it  had  been  impossible  to  immunise. 

The  general  mortality  of  the  French  Army  at  the 
front  dropped  almost  at  once,  and  kept  at  a  very  low 
level  as  soon  as  rigorous  measures  were  taken. 

It  cannot  be  doubted  that  if  typhoid  fever  has 
shown  itself  very  fatal  in  past  wars,  it  would  have 
been  destined  to  play  a  preponderant  role  in  the 
pathology  of  present  or  future  wars  if  prophylactic 
measures,  and  especially  vaccination,  had  not  been 
applied  energetically,  continuously  and  conscientiously. 


CHAPTER  VII 

ETIOLOGY   OF   TYPHOID   FEVER 

Favouring  Causes 

Typhoid  fever  is  due  to  a  special  bacillus  which, 
after  penetrating  into  the  organism,  is  disseminated 
in  the  blood  and  then  settles  in  the  lymphoid  organs, 
Peyer's  patches,  spleen,  bone-marrow,  liver  and  gall- 
bladder, and  nervous  system.  It  gives  rise  to  a 
toxi -injection,  the  symptoms  of  which  have  been 
described  in  the  first  part  of  this  work. 

This  bacillus  is  therefore  the  necessary  condition 
for  the  development  of  typhoid  fever. 

Its  mere  absorption,  however,  is  not  always  sufficient 
to  enable  it  to  multiply  and  give  rise  to  the  charac- 
teristic disease.  In  large  epidemics  the  members  of 
an  affected  community  do  not  all  contract  typhoid 
fever,  though  they  are  all  exposed  to  the  same  cause 
of  infection.  Some  have  such  mild  forms  of  the  in- 
fection that  it  passes  unnoticed,  even  by  the  patient. 
Others,  and  they  form  the  largest  number,  escape 
the  disease. 

In  like  manner  the  inhabitants  of  the  same  town 
who  have  drunk  the  same  contaminated  water,  the 
soldiers  living  in  the  same  barracks  and  exposed  to 
the  same  risk  of  contagion,  are  not  all  attacked  by 
typhoid  fever.     What  is  the  explanation  of  this  ? 

It  is  well  known  that  many  pathogenic  agents,  in 
order  to  grow  in  a  healthy  subject,  under  ordinary 
conditions,  require  a  certain  number  of  adjuvant 
circumstances  called  favouring  causes. 

Repeated  observations  have  illustrated  this  special 

104 


ETIOLOGY  :   FAVOURING  CAUSES  165 

influence  of  favouring  causes  in  the  etiology  of  tuber- 
culosis,   cere  bro -spinal    meningitis,    pneumonia,    etc 
There  are,  indeed,  few  diseases  in  which  these  causes 
play  so  important  a  part  as  in  typhoid  fever. 

Among  these  causes  there  are  some  which  may  be 
called  extrinsic,  i.  e.  independent  of  the  individual, 
such  as  the  influence  of  heat,  seasons,  etc.  Others, 
on  the  contrary,  are  inherent  in  the  individual,  one  of 
the  best  known  being  that  of  age. 

In  practice  it  is  necessary  to  become  familiar  with 
these  causes,  for  if  we  are  powerless  to  escape  from 
some  of  them,  we  should  be  alive  to  their  favouring 
action  and  take  measures  to  check  the  threatening 
infection  by  a  still  more  rigorous  prophylaxis. 

The  role  of  seasons  in  the  evolution  of  typhoid  fever 
has  long  been  known.  Although  it  may  appear  at 
all  seasons  of  the  year,  typhoid  fever  is  specially 
frequent  in  the  warm  season  and  in  the  autumn. 

The  observations  of  Murchison  in  England,  and  of 
Marc  d'Espine,  Besnier  and  Kelsch  in  France,  have 
shown  the  predominance  of  typhoid  fever  in  the 
sestivo -autumnal  period.  In  towns  where  the  disease 
is  endemic,  it  is  almost  always  in  summer  that  epidemic 
recrudescences  are  observed.  It  goes  without  saying 
that  there  is  no  absolute  rule  in  this  respect.  Some 
epidemics  have  occurred  in  winter,  like  the  epidemic 
at  Cherbourg  which  broke  out  suddenly  on  January 
25,  1909,  or  the  epidemic  at  Tours  which  began  in 
January  and  February  1914.  The  epidemic  which 
began  in  November  and  December  of  1914,  during  the 
great  war,  may  also  be  quoted. 

Generally  speaking,  however,  epidemic  cases  usually 
occur  in  the  months  of  July  and  August,  involving 
a  considerable  number  of  the  inhabitants  of  a  viUage 
or  town,  and  frequently  lasting  until  November. 

The  army  offers  every  year,  in  time  of  peace,  a  very 
remarkable  example  of  this  epidemic  rhythm.  The 
curve  of  all  the  cases  and  most  of  the  deaths  are  at 
their  lowest  level  during  the  winter  season.  They  rise, 
sometimes  suddenly,  on  the  appearance  of  the  warm 


166    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

season  and  keep  more  or  less  at  this  level  during  this 
period.  The  influence — an  indirect  one,  it  need  hardly 
136  said — of  the  external  temperature  on  the  annual 
course  of  epidemics  is  shown  by  the  fact  that  in  Algiers 
and  Tunis,  where  the  hot  season  occurs  earlier,  the 
rise  of  the  epidemic  curve  takes  place  a  month  sooner 
than  in  France ;  it  also  lasts  a  month  later. 

The  disease  is  also  much  more  frequent  in  that  part 
of  the  world. 

As  we  have  said,  the  towns  in  the  South  (Marseilles, 
Toulon,  Avignon,  Castres,  Beziers,  Narbonne,  Mont- 
peJlier,  Toulouse,  etc.)  are  among  those  in  which  the 
civn  population,  no  less  than  the  military,  pays  the 
liighest  toll  to  typhoid  fever. 

There  is,  therefore,  an  etiological  factor  which 
confers  a  cyclical  character  on  the  incidence  of  typhoid 
fever,  viz.  heat.  All  the  countries  on  the  shores  of 
the  Mediterranean,  as  well  as  hot  and  sub-tropical 
countries,  are  dangerous  foci  of  typhoid  fever.  The 
early  history  of  the  occupation  of  Morocco  was  marked 
by  a  very  severe  typhoid  mortality,  which  involved 
the  colonists  and  first  immigrants. 

These  insanitary  conditions,  resembling  those  which 
marked  the  occupation  of  Algeria  and  Tunis,  have 
to-day  been  entirely  removed — in  the  army  at  least. 

In  the  French  and  Belgian  Congo  the  colonists, 
manufacturers,  explorers,  trading  companies  and  com- 
panies for  developing  railways,  have  supplied  typhoid 
fever  with  numerous  victims.^ 

The  disease  remains  frequent  for  the  same  reason 
in  Egypt,  India,  Eritreea,  Central  America,  the  Philip- 
pines, etc. 

All  infectious  diseases  with  an  intestinal  localisation, 
such  as  dysentery,  cholera,  infantile  and  ordinary 
diarrhoea,  show  an  epidemic  fastigium  which  coincides 
with  the  high  temperature  and  hot  weather. 

1  The  influence  of  heat  is  shown  not  only  by  the  number  of  cases 
of  typhoid  fever,  but  also  by  their  gravity,  to  which  it  adds  con- 
siderably. The  severity  of  the  symptoms  and  percentage  mortality 
are  much  greater  in  warm  countries. 


ETIOLOGY :   FAVOURING  CAUSES 


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168    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

In  addition  to  these  sestivo -autumnal  variations 
of  enteric  fever,  multi -annual  variations  have  been 
noted  (Besnier),  i.e.  recrudescences  of  epidemics  every 
five,  six  or  seven  years.  They  are  due  to  the  arrival 
in  the  same  infected  locality  or  town  of  new  and 
susceptible  subjects.  The  proportion  of  susceptible 
individuals  is  also  increased  by  a  certain  number  of 
births. 

In  an  estimation  of  the  favouring  causes  inherent 
in  the  man  himself,  and  which  act  either  as  a  check 
or  as  an  aggravation  of  the  typhoid  infection,  much 
importance  must  be  attributed  to  the  influence  of  a 
previous  attack,  as  well  as  to  that  of  age,  race  and 
overwork. 

The  immunity  conferred  by  a  previous  attack  of 
typhoid  fever  is  very  great,  but  it  is  not,  however, 
absolute  or  permanent  for  a  certain  number  of  indi- 
viduals. It  may  be  calculated  that  1  to  2  per  cent, 
of  those  who  have  had  typhoid  fever  are  liable  to 
contract  it  a  second  time.  The  second  attack  is 
usually  milder.  The  interval  between  the  two  attacks 
is  from  two  years  (very  exceptional)  to  seven  years 
and  more.  The  second  attack  of  typhoid  fever  fairly 
often  occurs  after  a  journey  abroad,  where  the  subject 
is  contaminated  by  other  strains  of  the  bacillus,  as 
has  been  seen  in  colonists  or  travellers  to  Morocco. 
Similar  observations  have  been  made  in  the  case  of 
malaria. 

There  seems  to  be  a  familial  predisposition  for 
typhoid  fever. 

It  is  not  uncommon  to  see  an  abnormal  number  of 
cases  of  this  disease  among  members  of  certain  families, 
living  under  different  conditions  and  in  different 
areas.  On  the  other  hand,  there  is  no  doubt  that 
certain  individuals  or  races  are  immune. 

As  we  have  seen,  typhoid  fever  is  an  ubiquitous 
disease.  All  races  are  liable  to  it.  During  the  War 
of  Secession  the  coloured  troops,  though  they  were 
less  affected  than  the  others,  nevertheless  had  192-14 
cases  per   1000  and   57-71   deaths  per   1000.     In  the 


ETIOLOGY  :   FAVOURING  CAUSES  169 

Eritrsean  Campaign  the  native  troops  and  porters 
suffered,  though  in  a  less  proportion,  from  the  same 
disease. 

The  Germanic  race  is  as  liable  to  typhoid  infection 
as  the  Latin.  Not  only  was  typhoid  fever  frequent 
in  the  ranks  of  the  German  army  in  1870-71  and  in 
the  present  war,  but  the  German  prisoners  sent  to 
Morocco  showed,  shortly  after  their  arrival,  some 
epidemic  cases,  which  were  immediately  checked  and 
arrested  by  preventive  vaccination. 

The  Japanese  race  has  little  susceptibility,  as  was 
proved  by  the  rarity  of  attacks  in  the  Japanese  army 
during  the  Manchurian  War,  in  which  the  number  of 
cases  was  four  times  less  than  in  the  Russian  army. 
The  same  was  found  to  be  the  case  on  the  occasion 
of  the  Expedition  to  China  in  1901  (Shimosa). 

Is  this  relative  immunity  the  result  of  previous 
attacks  in  childhood  among  the  Japanese,  or  is  it  the 
result  of  the  YQiy  rigorous  prophylaxis  adopted  by  the 
Japanese  troops  ?  It  is  impossible  to  say.  The  same 
question,  namely,  the  influence  of  racial  immunity, 
is  suggested  by  the  Arabian  and  Hindoo  races.  In 
spite  of  very  bad  hygienic  conditions,  the  Indians 
rarel}^  suffer  irom  typhoid  fever.  It  is  the  same  with 
the  Herreros.  A  comparison  of  the  incidence  of 
typhoid  fever  in  Algeria  among  the  Arab  troops  with 
that  among  the  French  troops  living  in  the  same 
garrison  towns  has  shown  that  the  former  had  80  to 
100  fewer  cases  of  tj^phoid  fever  than  the  latter  (H. 
Vincent).  As  a  matter  of  fact,  the  Arabs  in  Algeria 
include  men  of  Aryan  race  (Kabyles),  who  are  very 
susceptible.  On  the  other  hand,  the  transfer  of  Arab 
soldiers  to  Morocco  has  revealed  the  frequency^  and 
gra^dty  of  typhoid  fever  among  them.  There  is, 
therefore,  some  reason  to  think  that  those  who  have 
not  been  attacked  possess  an  acquired  immunity,  the 
result  of  typhoid  fever  contracted  in  childhood,  rather 
than  a  spontaneous  or  racial  immunity. 

A  similar  reason  may  be  given  to  explain,  on  the 
one  hand,   the  lesser  frequency  of  typhoid  fever  in 


170    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

inhabitants  of  large  towns,  and,  on  the  other  hand, 
the  high  susceptibility  of  country  people  who  have 
been  uprooted  and  transplanted  into  towns.  The 
emigration  of  rural  populations  into  towns  exposes 
them,  among  other  dangers,  to  attacks  of  infectious 
disease,  and  especially  typhoid  fever.  Servants  of 
both  sexes  and  employees  from  the  country  who  take 
up  situations  in  towns  in  w^hich  the  sanitary  conditions 
are  defective  and  the  drinking  water  is  contaminated, 
are  before  long  attacked  by  the  typhoid  bacillus, 
especially  if  they  are  young.  The  same  observation 
was  made  long  ago  in  armies,  even  during  the  War 
of  Secession. 

Typhoid  fever  may  be  observed  at  all  ages.  A 
pregnant  woman,  when  attacked  by  this  disease,  may 
communicate  it  to  her  foetus,  as  has  been  shoAvn  by 
numerous  examples. 

Typhoid  fever  may  also  attack  old  men  of  eighty 
years  and  over.  But  all  epidemiologists  have  noted 
the  exceptional  frequency  of  the  disease  during  adoles- 
cence, and  especially  in  young  men  or  women,  single 
or  married.  The  largest  number  of  cases  usually 
occurs  about  the  twenty-first  year.^  Byouardel,  in 
an  analysis  of  10,036  deaths  from  typhoid  fever,  found 
that  3896,  or  more  than  a  quarter  of  the  deaths,  occurred 
between  the  ages  of  twenty  and  twenty -five. 

J.  Bertillon  says  :  "  The  frequency  of  typhoid  fever 
is  considerable  after  the  second  year  of  life ;  then  it 
rises  until  twenty  to  twenty-five  years  of  age,  when  it 
reaches  its  maximum ^ 

The  male  sex  is  much  more  frequently  affected 
than  the  female,  with  the  exception  of  the  first  years 
of  life. 

The  increase  in  the  incidence  of  typhoid  fever  from 
twenty  to  twenty-four  years  of  age  specially  applies 
to  the  male  sex  :    at  this  age  there  are  fewer  cases  of 

1  According  to  Murchison,  out  of  100  cases  of  typhoid  fever, 
46-5  are  observed  from  fifteen  to  twenty-five  years;  the  average 
age  at  which  typhoid  fever  is  most  frequently  contracted  is  twenty- 
one  years. 


ETIOLOGY :   FAVOURING  CAUSES 


171 


typhoid  fever  in  the  female  sex  than  between  fifteen 
and  nineteen  years  of  age. 

From  1876-1905  the  average  annual  mortality  from 
typhoid  fever  in  Paris  among  100,000  inhabitants 
was  as  follows — 


From  0  to 

55  i      55 

55  "^      55 

„  10 

„  15 

55  20 

,5  25 

5,  30 

5,  35 

5,  40 

5,  45 

„  50 

55  55 

5,  60 

„  65 

,5  70 

„  75 
80 


1  year 


9-2 


4  years 50-9 


9 
14 
19 
24 
29 
34 
39 
44 
49 
54 
59 
64 
69 
74 
79 


Over 


51-3 

62-0 

95-7 

94-01 

53-8 

350 

25-4 

17-9 

16-7 

12-3 

10-4 

8-7 

8-0 

5-7 

60 

71 


These  figures,  which  have  been  taken  from  J. 
Bertillon's  statistics,  show  that  the  curve  of  typhoid 
fever  is  fairly  low  in  the  first  year  of  life,  rises  suddenly 
from  one  to  four  years — that  is  to  say,  from  the  time 
when  the  chUd  changes  his  milk  diet  for  one  approxi- 
mating to  that  of  an  adult. — keeps  at  about  the  same 
level  up  to  fourteen  years  of  age,  then  shows  a  new 
rise,  this  time  a  maximal  one,  between  fifteen  and 
twenty -four  years.  Young  persons  of  the  male  sex 
are  most  frequently  attacked  between  the  ages  of  twenty 
and  twenty-four.  The  frequency  of  typhoid  fever 
remains  high  up  to  thirty,  and  then  progressively 
falls,  a  phenomenon  which  is  perhaps  explained  not 
only  by  the  diminished  susceptibility  of  advanced 
life,  but  also  by  the  immunity  resulting  from  a  former 
attack. 

1  From  1886-1905  the  average  death-rate  at  this  age  was  104-7 
per  100,000  inhabitants.  The  male  sex  had  67-1  deaths,  the  female 
sex  37-6. 


172    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  previous  observations,  on  which  Prof.  Brouardel 
often  insisted,  furnish  the  explanation  of  the  predilec- 
tion which  typhoid  fever  has  always  had  for  the  army. 
Brouardel  has  dwelt  on  the  principal  reason  for  this. 
"  Statistics,"  he  says,  "  show  that  among  10,000 
soldiers  living  in  France  from  1875-1901  there  were 
11-2  deaths  from  typhoid  fever,  whereas  a  similar 
group  of  100,000  civilians  loses  only  3-8."  This 
difference  can  easily  be  explained. 

"  In  the  population  of  towns,  individuals  from 
fifteen  to  twenty-five  represent  almost  one-sixth  of 
the  total  population.  Now  it  is  in  this  sixth  part  in 
which  is  to  be  found  46-5  per  cent,  of  the  cases  of 
typhoid  fever,  i.e.  half  of  the  deaths  from  the  disease. 
This  amounts  to  saying  that  one -sixth  of  the  civil 
population  furnishes  half  the  deaths  from  typhoid 
fever. 

"  If  the  civil  population  is  divided  by  six,  and  the 
typhoid  deaths  by  two,  and  if  the  proportion  per 
10,000  inhabitants  be  worked  out,  it  will  be  found 
that  the  group  of  fifteen  to  twenty-five  years  yields 
a  mortality  of  11-5  per  10,000  civilians,  while  that  of 
the  army  is  11-2."  ^ 

For  many  other  reasons,  also,  a  close  comparison 
cannot  be  made  between  the  morbidity  of  the  civil 
population  of  towns  and  that  of  the  army,  which  is 
in  great  part  composed  of  very  susceptible  inhabitants 
fro'tai  the  country.  Furthermore,  a  condition  peculiar 
to  the  army,  without  any  analogy  in  the  civil  population, 
is  constituted  by  the  regular  arrival,  every  three  years 
before  the  law  of  March  21,  1905,  and  every  two  years 
since  that  date,  of  soldiers  who  formed  part- of  the  army 
in  time  of  peace.  Epidemic  diseases  are  thus  supplied 
with  fresh  life  at  frequent  intervals,  and  chances  of 
infection  in  a  military  environment  are  considerably 
multiplied. 

Moreover,  in  the  army  soldiers  who  have  only  had 

1  This  incidence  of  typhoid  fever  in  the  French  army  has  con- 
siderably declined.  In  the  years  1909,  1910,  1911,  it  was  4-7,  3-1 
and  4-6  respectively  per  10,000. 


ETIOLOGY:   FAVOURING  CAUSES  173 

one  year  of  service  always  show  a  higher  incidence 
of  typhoid  fever  than  old  soldiers. 

The  same  peculiarity  has  been  noted  in  foreign 
armies.  Thus  in  the  English  army  in  India,  in  1899, 
the  soldiers  under  twenty  had  18-8  cases  of  typhoid 
fever  per  10,000. 

The  soldiers  aged  from  20-25  had  31-3  cases  per  1000. 

>j  >5  5j  5»        ^5— dO      ,,       ll'O       ,,  ,,  ,, 

»>  >»  »»         j>      oU— oo     ,,       0"o      ,,        ,,        ,, 

Of  all  the  favouring  causes  which  predispose  most  to 
typhoid  infection,  none  is  more  powerful,  than  fatigue 
and  ovenvorJc.  The  influence  of  these  two  factors  is 
united  in  war,  especially  in  those  which  are  violent, 
and  prolonged,  like  the  present  war. 

There  is,  indeed,  no  condition  which  involves  such 
an  expenditure  of  moral  and  physical  energy  as  war. 

Acute  overwork  may  of  itself  cause  death,  as  is  seen 
in  the  case  of  trained  animals,  such  as  carrier  pigeons. 
Fatigue  and  absence  of  sleep  cause  a  veritable  auto- 
intoxication. The  urine  and  blood,  which  reveal  the 
saturation  of  the  organism  by  waste  products,  are 
three  to  four  times  more  toxic  than  normally.  For 
this  reason,  after  excessive  fatigue,  and  at  the  moment 
of  recovery,  an  extraordinary  output  of  urea  may  be 
observed  (even  up  to  126  grammes  in  twenty -four 
hours,  according  to  Revilliod). 

The  clinical  experiments  of  Charrin  and  Roger 
showed  long  ago  the  predisposing  role  of  fatigue  in 
infections.  The  same  factor  diminishes  the  principal 
protective  element  in  the  serum,  viz.  alexine  (H. 
Vincent).  It  is  easy  to  understand  why  individuals 
who  have  been  deprived  of  part  of  their  means  of 
defence  are  less  successful  in  resisting  infections'",  and 
especially  such  frequent  infectious  diseases  as  typhoid 
and  paratyphoid  fevers. 

Typhoid  fever  is  pre-eminently  the  disease  of  the 
overworked,  and,  consequently,  of  war.  We  have 
already  seen  the  excessive  frequency  of  this  disease. 
The  war  in  Manchuria  was  alone  an  exception  to  this 


174    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

law.  The  favourable  sanitary  state  of  the  Russian 
and  Japanese  armies  is  explained  not  only  by  the 
hygienic  measures  adopted  by  the  belligerents,  but  also 
because  fatigue  was  almost  unknown  by  the  soldiers. 
The  war  was  characterised  by  very  long  intervals  of 
rest,  interrupted  by  a  few  violent  battles. 

No  condition,  therefore,  predisposes  so  strongly  to 
typhoid  fever  as  war,  especially  war  during  the  sestivo- 
autumnal  season,  because  the  depressing  action  of 
heat  is  added  to  that  of  excessive  fatigue.  During 
the  Tunis  Expedition  every  prolonged  march  was 
foUov/ed  by  a  recrudescence  of  typhoid  fever. 


CHAPTER  VIII 

ETIOLOGY  OF  TYPHOID  FEVER — THE  HUMAN  FACTOR — 
ITS    DETERMINING    CAUSES 

We  studied  in  the  last  chapter  the  principal  con- 
ditions favouring  the  outbreak  of  infection  due  to 
the  typhoid  bacillus.  By  themselves  alone  they  are 
obviously  unable  to  give  rise  to  the  disease. 

They  arouse  the  infection,  but  do  not  create  it. 

Further,  the  disease  may  quite  well  develop  in  a 
perfectly  healthy  subject  and  in  the  absence  of  these 
predisposing  factors.  It  is  none  the  less  true  that  they 
are  often  at  work  either  to  help  on  the  infection  or  to 
exaggerate  it. 

The  typhoid  bacillus  is  the  chief  cause  of  the  in- 
fection. Its  most  constant  portal  of  entry  is  the 
alimentary  canal. 

After  penetrating  into  the  organism  by  the  stomach, 
the  bacillus  is  or  may  be  rapidly  absorbed  by  the  small 
intestine,  especially  when  it  is  swallowed  in  a  fasting 
condition,  with  impure  water,  for  example,  or  at  the 
beginning  of  a  meal  with  such  food  as  oysters. 

The  very  frequent  existence  of  tonsillitis  or  sore 
throat  at  the  onset  of  typhoid  fever,  which  is  seen  in 
40  per  cent,  of  the  cases,  shows  that  the  tonsils  are  a 
fairly  common  portal  of  entry  for  the  tj^hoid  bacillus. 
In  some  very  exceptional  cases  the  ulcerative  lesion 
of  the  pharynx  seems,  in  association  \\ith  the  fever, 
to  be  the  only  localisation  of  the  infection  (pharjTigo- 
typhoid).  Although  the  bacillus  has  been  isolated  in 
the  tonsillar  exudate  (GaUois)  these  lesions  should  be 
regarded  as  the  result  of  a  secondary  gTO^\'th,  as  is  also 
the  case  vnth.  the  spleen  (splenomegaly)  and  Peyer's 
patches. 

175 


176    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  old  opinions  relating  to  the  modes  of  infection 
and  penetration  of  the  system  by  the  typhoid  bacillus 
have  been  modified  or  rendered  more  accurate  by 
modern  research.  It  was  for  a  long  time  believed  that 
the  typhoid  bacillus  grew  plentifully  in  the  cavity  and 
walls  of  the  intestine,  and  thence  disseminated  the 
toxins  which  poisoned  the  patient.  In  reality  this 
mode  of  infection,  which  is  that  of  bacillary  dysentery 
and  cholera,  is  not  applicable  to  typhoid  fever. 

The  growth  of  the  typhoid  bacillus  in  the  intestine 
is  inhibited  by  the  co -existence  of  bacteria  which  live 
there. 

Among  these  hostile  micro-organisms  the  B.  coli  in 
particular  should  be  mentioned.  This  struggle  be- 
tween the  saprophytes,  which  can  easily  be  verified 
in  vitro,  takes  place  in  the  same  manner  in  the  digestive 
tube.  Moreover,  if  a  search  is  made  for  the  typhoid 
bacillus  in  the  body  after  death,  it  is  found  that  the 
pathogenic  microbe  diminishes  in  frequency  towards 
the  lower  end  of  the  intestine. 

In  reality,  the  typhoid  bacillus  after  being  absorbed 
by  the  digestive  tract  finds  a  secondary  habitat  in  the 
viscera,  after  having  first  passed  through  the  blood. 

This  septicaemic  period  appears  to  be  a  silent 
one. 

As  the  result  of  systematic  cultures  of  the  blood  the 
typhoid  bacillus  has  been  isolated  during  the  incubation 
period,  and  in  the  absence  of  any  symptoms,  several 
days  before  the  appearance  of  the  prodromes  of  the 
disease.  It  has  also  been  found  in  the  blood  of  some 
healthy  subjects  who  have  been  contaminated,  but 
nevertheless  escape  typhoid  fever  (J.  Louis),  doubtless 
because  they  possess  a  certain  degreie  of  immunity. 

From  the  blood  the  typhoid  bacillus  is  carried  into 
all  the  organs  and  also  into  the  central  nervous  system. 
It  settles  by  choice  in  Peyer's  patches,  corresponding 
mesenteric  glands,  spleen,  bone-marrow,  liver  and  gall- 
bladder. 

The  presence  of  the  typhoid  bacillus  in  the  patient's 
blood  was  noted  a  very  long  time  ago,  during  life,  by 


ETIOLOGY  :   DETERMINING  CAUSES         177 

J.  Teissier,   Busquet,   Castellani,   Warfeld,   Courmont, 
Lemierre,  etc.,  and  after  death  by  H.  Vincent. 

As  soon  as  the  febrile  symptoms  appear,  the  bacillus 
is  almost  constantly  present  in  the  blood.  Coleman 
and  Hiixon,  in  the  examination  of  eighty-five  cases, 
fomid  it 

during  the  first  week  in  93  per  cent. 
„         „    second  „       76        „ 
„    third      „        5G 

It  may  also  be  found  by  cultures  for  a  period  of 
one  to  four  days  in  the  blood  of  animals  infected 
experimentally. 

The  early  appearance  of  the  typhoid  bacillus  in  the 
blood  thus  shows  that  the  specific  enteritis,  i.  e.  the 
period  of  diarrhoea  with  necrosis  of  Peyer's  patches  and 
intestinal  haemorrhage  is  preceded  by  a  very  important 
stage  of  bacillcemia. 

It  is  necessary  to  bear  this  explanation  in  mind  if 
one  wishes  to  understand  the  means  by  which  the 
typhoid  bacillus  can  be  eliminated  and  thus  spread  the 
contagion. 

After  having  invaded  the  blood,  the  bacillus  is 
carried  by  it  to  all  the  viscera.  From  the  epidemio- 
logical standpoint  this  is  a  fact  of  great  importance,  for 
some  of  these  viscera  have  excretory  ducts  or  organs  ivhich 
communicate  ivith  the  exterior,  e.  g.  the  liver  by  means 
of  the  gall  bladder  and  common  bile  duct,  and  the 
kidneys  by  the  ureters  and  bladder. 

From  the  onset  of  the  disease,  and  indeed  even  from 
one  to  twenty-five  days  (in  cases  with  a  long  incuba- 
tion) before  the  appearance  of  febrile  symptoms,  the 
typhoid  patient  is  contagious,  and  eliminates  the  patho- 
genic bacillus  in  his  excreta. 

It  is  unlikely,  at  least  at  this  initial  period,  that 
these  bacilli  come  exclusively  from  the  mucous  mem- 
brane and  glands  of  the  intestine. 

On  the  other  hand,  from  the  moment  that  the  bacillus 
invades  the  blood,  the  liver  and  gall  bladder  form  the 
principal  route  for  elimination  of  the  bacillus  of  typhoid 
fever.     The  bacillus  is  also  to  be  found  in  great  numbers 


178    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

in  the  stools,  to  which  it  communicates  their  contagious 
character. 

The  conveyance  of  the  bacillus  to  the  gall  bladder 
in  which  it  grows  is  effected,  not  by  the  ascending 
route,  i.  e.  from  the  intestine  to  the  gall-bladder  by 
means  of  the  common  bile  duct,  but  by  the  liver,  or, 
according  to  Chiarolanza,  by  the  blood  capillaries  of 
the  submucosa,  where  they  perhaps  form  emboli, 
which  facilitate  their  passage  into  the  gall-bladder. 

Lemierre  and  Abrami  hold  that  damage  to  the 
hepatic  parenchyma  allows  the  passage  of  the  bacillus 
into  the  bile. 

Whatever  may  be  the  means  by  which  it  is  con- 
veyed, the  almost  constant  presence  of  the  bacillus  in 
the  bile  remains  a  well-proved  fact. 

It  may  be  absent,  but  this  is  a  rare  occurrence.  When 
it  reaches  the  gall-bladder  it  grows  there  as  readily  as 
in  a  culture -tube,  finding  a  suitable  medium  which  is 
constantly  being  renewed  and  eliminated,  and  thereby 
carries  the  bacillus  with  it  into  the  duodenum  and 
discharges  it  with  the  excreta. 

An  attempt  has  been  made  by  means  of  experiments 
to  elucidate  the  problem,  which  is  so  interesting  from 
a  pathogenic  and  epidemiological  point  of  view,  of  the 
existence  of  the  typhoid  bacillus  in  the  gall-bladder. 
As  a  matter  of  fact,  animals  form  an  unsuitable  field 
for  inquiry,  because,  with  the  exception  of  the  monkey, 
they  present  a  very  low  susceptibility  for  typhoid  in- 
fection. Though  very  sensitive  as  regards  the  toxine, 
it  is  only  under  very  rare  and  special  circumstances 
that  they  show  symptoms  of  true  septicaemia. 

Investigators,  however,  have  succeeded  in  injecting 
the  typhoid  bacillus  into  the  vein  of  a  rabbit,  and  find- 
ing it  in  the  gall-bladder  when  the  animals  were  IdUed 
at  different  dates.  Thus  the  bacillus  has  been  found 
to  persist  in  the  bile  of  a  rabbit  for  three  and  even  four 
months.  This  long  persistence  of  the  bacillus  in  an 
animal  is  doubtful,  and  the  same  experiments  have  by  no 
means  given  a  similar  result  in  the  hands  of  other  writers. 

In  man  the  existence  of  the  typhoid  bacillus  in  the 


ETIOLOGY  :    DETERMINING  CAUSES         179 

contents  of  the  gall-bladder  may  be  found  by  cultures 
after  death.  In  the  patient,  Boldyreff's  test,  i.  e.  the 
injection  of  200  grammes  of  oil,  causes  a  reflux  of  bile 
into  the  stomach,  from  which  the  bacillus  can  be 
isolated.  It  has  been  possible  to  find  the  micro- 
organism by  this  method,  even*  when  examination  of 
the  stools  had  been  negative.  Lastly,  Carnot  and  Weill - 
Halle  have  introduced  a  very  interesting  method  by 
which  the  typhoid  bacillus  can  be  sought  for  and 
isolated  in  the  duodenum  by  means  of  a  rubber  tube. 

An  explanation  is  thus  obtained  of  the  presence  of  the 
lymphoid  bacillus  in  a  patient's  stools.  The  chief  sources 
from  which  the  bacillus  comes  are  :  (1)  Infected  bile; 
(2)  Intestinal  ulceration ;  (3)  Extravasation  from  the 
capillaries  of  the  intestinal  submucosa  (Chiarolanza). 

This  elimination,  which  is  so  important  from  an 
epidemiological  standpoint,  can  be  verified  by  cultiva- 
tion of  the  stools. 

The  date  of  appearance  of  the  typhoid  bacillus  in 
the  stools  is  very  early,  its  presence  having  been 
observed  before  the  febrile  period  and  even  before  the 
first  symptoms. 

We  may  remind  the  reader  that  typhoid  fever  is 
preceded  by  an  incubation  period  which  may  be  as 
short  as  fourteen' or  fifteen  days,  but  which  may  be 
prolonged  to  three  or  four  weeks,  or  even  forty  or  forty- 
five  days.  The  result  is  that  the  subject  who  is  incubat- 
ing typhoid  fever  may  have  been  disseminating  the 
pathogenic  bacillus  by  direct  or  indirect  contagion  for  a 
long  time  without  there  being  any  signs  to  reveal  it. 

As  soon  as  the  symptoms  of  the  disease  appear,  and 
the  typhoid  diarrhoea  sets  in,  there  is  an  abundant 
elimination  of  the  bacillus,  especially  during  the  attacks 
of  diarrhoea.  In  cases  in  which  the  biliary  secretion 
is  increased  the  intestinal  content  is  rapidly  eliminated 
and  is  very  rich  in  bacilli. 

The  liquid  character  of  the  faeces  facilitates  their 
dispersion,  and  consequently  the  likelihood  of  con- 
tagion among  those  who  are  looking  after  the  patient. 

The  excretion  of  bacilli  is  most  copious  during  the 


180    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

first  fortnight,  and  then  diminishes.  Some  writers 
think  that  the  maximum  frequency  of  the  bacilli  in 
the  stools  occurs  at  the  onset  of  convalescence  ( ?).  It 
is  women  especially  who  have  been  weakened  by  a 
protracted  attack  of  typhoid  fever  who  eliminate  most 
bacilli. 

We  may  conclude  from  the  foregoing  that  the  patient 
excretes  the  bacillus  and  that  consequently  he  is  con- 
tagious before  the  appearance  of  the  febrile  symptoms 
and  throughout  the  duration  of  his  infection. 

In  hospitals  patients  suffering  from  characteristic 
forms  of  typhoid  fever  are  usually  isolated  and  are 
subject  to  precautions  which  remove  or  restrict  the 
dangers  of  contagion.  But  in  families,  especially  in 
poor  families  or  in  the  country,  the  contagion  may 
spread  with  extraordinary  facility. 

Hence  those  epidemics  in  families  or  villages  in 
which  a  large  proportion  of  the  members  or  inhabitants 
are  successively  attacked.  Individuals  who  have  mild 
forms  of  the  infection  which  are  laiown  as  abortive, 
attenuated  (typhus  levissimus)  or  ambulatory,  con- 
stitute some  of  the  most  dangerous  agents  of  contagion 
because  they  are  unrecognised.  Such  patients  may  be 
walking  about  and  even  be  engaged  in  their  ordinary 
occupations  for  several  weeks,  while  they  are  dissemi- 
nating the  bacilli  in  their  excretions,  contaminating 
their  neighbours  and  sometimes  creating  fresh  foci  of 
infection  at  a  distance. 

Children  often  serve  as  unrecognised  agents  in  the 
dissemination  of  the  typhoid  bacillus  by  means  of 
their  excreta.  Contrary  to  the  generally  accepted  view 
they  are  very  susceptible  to  this  disease.  Usually, 
however,  they  have  only  slight  attacks  accompanied 
by  a  weak  febrile  reaction,  but  on  the  other  hand  by 
diarrhoea,  which  may  be  profuse. 

The  stools  of  patients  suffering  from  typhoid  fever 
consequently  form  the  most  important  means  of  con- 
tagion on  account  of  the  bacillus  which  they  contain. 

There  are  other  means  of  contagion  which  we  will 
now  discuss. 


ETIOLOGY  :   DETERMINING  CAUSES         181 

It  is  well  known  that  typhoid  patients  in  the  course 
of  their  disease  fairly  often  have  albuminuria  and  bacil- 
luria.  Although  these  two  phenomena  are  not  in- 
variably associated,  they  may  accompany  each  other. 
The  discharge  of  typhoid  bacilli  in  the  patient's  urine 
was  described  long  ago  by  various  writers  (Neumann, 
Petruschky,  Richardson,  Wright  and  Semple,  etc.). 
As  in  the  case  of  the  faeces,  though  in  a  less  degree,  the 
isolation  of  the  typhoid  bacillus  in  the  urine  presents 
difficulties.  This  is  particularly  the  case  when  B.  coli 
is  also  present.  The  presence  of  the  typhoid  bacillus 
in  the  urine  of  patients  varies.  Wright  and  Semple 
found  it  in  five  out  of  six  patients. 

Other  authors  isolated  it  in  only  19  per  cent. 
(H.  Vincent).  As  in  the  case  of  the  gall-bladder  the 
bacillus  may  multiply  in  the  bladder  and  cause  an 
inflammation  of  its  walls  and  even  hsemorrhagic  cystitis. 

Cases  of  hsemorrhagic  nephritis  due  to  the  growth  of 
the  bacillus  in  the  renal  parenchyma  may  also  be 
observed  in  the  course  of  typhoid  fever. 

In  these  various  cases  the  iirine  becomes  a  factor  of 
contOjgion  which  is  by  no  means  negligible. 

The  appearance  of  the  typhoid  bacillus  in  the  urine 
in  typhoid  fever  is  not  so  early  as  in  the  biliary  secre- 
tion. Whereas  the  bile  forms  a  favourable  culture 
medium  for  this  bacillus — a  property  taken  advantage 
of  for  the  isolation  and  cultivation  of  typhoid  bacilli 
(and  paratyphoid  bacilli) — the  same  cannot  be  said  of 
the  urine,  which  is  an  acid  and  innutritions  medium. 

It  is  none  the  less  true  that  the  passage  of  the  typhoid 
bacillus  into  the  patients'  urine  may  play  a  part  in  the 
transmission  of  the  disease. 

It  will  be  seen  later  that  the  typhoid  bacillus  may 
persist  sometimes  for  a  very  long  period  after  recovery 
in  the  gall-bladder,  andt  consequently  in  the  stools,  as 
well  as  in  the  bladder  and  urine. 

There  are  a  certain  number  of  atypical  forms  of  in- 
fection due  to  the  typhoid  bacillus,  which  undoubtedly 
have  a  share  in  the  transmission  of  typhoid  fever. 
Such  are  the  cases  of  septicaemia  without  intestinal 


182    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

lesions,  of  which  examples  have  been  pubHshed,  and 
certain  forms  of  appendicitis  (Drigalski,  Stokes  and 
Amick),  suppurative  otitis,  bronchitis  with  obstinate 
bronchorrhsea  without  signs  of  typhoid  fever,  etc. 
Netter  has  observed  instances  of  vulvitis  due  to  the 
same  infection  in  little  girls. 

More  closely  associated  with  typhoid  fever  are  the 
late  typhoid  infections  of  the  gall  bladder  and  bile  ducts, 
which  very  often  occur  in  an  apparently  spontaneous 
manner  and  independentlj^  of  any  previous  attack  of 
typhoid  fever.  The  typhoid  bacillus  has  none  the  less 
penetrated  into  the  organism  at  some  time  or  other, 
sometimes  without  causing  any  immediate  reaction, 
sometimes  giving  rise  to  a  slight  and  overlooked 
affection,  but  in  any  case  after  a  phase  of  latent 
septicaemia. 

The  importance  of  these  foci  of  contagion  from  an 
etiological  and  hygienic  point  of  view  cannot  be  denied. 
By  isolating  the  typhoid  bacillus  from  the  bile,  after 
operations  and  at  autopsies  on  patients  suffering  from 
hepatic  colic,  acute  or  chronic  angiocholitis,  chole- 
cystitis a.nd  jaundice,  Dupre,  Dauriac,  and  Gilbert  an^ 
Fournier  made  a  highly  valuable  contribution  to  medical 
science,  whereby  this  class  of  patients  may  be  classified 
as  germ  carriers.  The  bacillus  has  been  isolated  from 
gall  stones. 

Paratyphoid  bacilli  also  may  be  responsible  for  the 
,same  lesions.  A  certain  number  of  cases  of  surgical 
contagion  shows  that  this  factor  is  not  an  exception 
(Ribadeau -Dumas  and  Debre).  Wherever  the  typhoid 
bacillus  can  grow,  and  in  whatsoever  condition  it  may 
multiply,  such  as  cholecystitis,  suppuration,  abscesses, 
osteitis,  or  periostitis,  thyroiditis,  parotitis,  etc.,  it  is 
liable  to  be  contagious. 

But  transmission  of  contagion  in  this  manner  is  much 
less  frequent  than  by  the  faeces  or  urine. 

It  is  not  unreasonable  to  suppose  that  the  typhoid 
bacillus  may  exist  in  other  pathological  products,  or  be 
propagated  by  other  natural  secretions.  It  may  occur 
in  the  blood  from  epistaxis  or  intestinal  haemorrhage. 


ETIOLOGY  :   DETERMINING  CAUSES         183 

The  pharyngeal  lesions  occurring  at  the  onset  or  in 
the  course  of  t5rphoid  fever,  such  as  Duguet's  ulcers, 
may  explain  the  presence  of  the  bacillus  in  the  saliva 
in  which  Dvouyeglasoff  and  Chantemesse  have  found  it, 
the  former  in  two  out  of  fifteen  cases,  on  the  twelfth 
and  twentj^'-fifth  days  of  disease.  Manicatide,  who  took 
cultures  from  the  pharyngeal  and  tonsillar  secretions  of 
fifty -one  patients,  isolated  the  bacillus  in  thirty -six 
cases.  Gallois  has  insisted  on  the  importance  of  the 
rhino -pharyngitis,  which  is  a  fairly  frequent  prelude 
to  typhoid  fever.  Systematic  cultivation  of  the  saliva, 
however,  by  other  writers,  did  not  show  the  bacillus. 

Do  the  bronchial  secretions  of  patients  with  pul- 
monary complications  contain  the  bacillus  ? 

Jehle  says  that  he  found  it  in  nine  out  of  fifteen 
cases  after  death.  We  have  already  alluded  to  the 
fact  that  certain  forms  of  bronchitis,  with  abundant 
expectoration,  are  rich  in  bacilli. 

As  a  matter  of  fact,  pulmonary  complications  occur- 
ring in  typhoid  fever  are  due  to  secondary  infections  of 
the  parenchyma  or  bronchi.  Bacteriological  examina- 
tion shows  the  staphylococcus  or  streptococcus,  which 
are  the  real  cause  of  these  infections,  and  in  cases  of 
pneumonia  the  pneumococcus  alone  (H.  Vincent).  The 
typhoid  bacillus  is  found  in  the  lung,  but  not  as  a  rule 
in  the  spitting-cup.  If,  however,  the  lesion  is  ac- 
companied by  ulceration  or  haemorrhage,  the  typhoid 
bacillus  may  be  entangled  in  the  pus  or  blood,  and  thus 
become  an  exceptional  agent  of  contagion. 

The  same  remark  applies  to  the  healthy  and  damaged 
skin  (bed  sores),  and  the  sweat,  in  which  Sudakoff  and 
Wigura  isolated  the  bacillus. 

But  contamination  by  faeces  and  bath  water  are 
sufficient  to  explain  its  presence  on  the  surface  of  the 
skin. 

In  the  case  of  two  nursing  women  suffering  from 
typhoid  fever,  Chantemesse  and  Widal  were  unable  to 
discover  the  bacillus  in  the  milk,  but  Lawrence  says 
that  he  isolated  it  in  one  case  of  the  kind. 

Bilious  vomit  may  contain  the  baciUi  in  very  large 


184    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

numbers.  This  vomiting,  which  occurs  at  the  onset  of 
typhoid  fever,  is  connected  with  the  infection  of  the 
bile  passages.  The  reflux  of  bile  into  the  stomach  and 
its  hyper-secretion  brings  with  it  a  number  of  contagious 
bacilli. 

We  may  conclude  from  the  foregoing  that  the  ty- 
phoid bacillus  is  eliminated  by  the  patient  before  any 
symptoms  appear,  and  throughout  the  duration  of  the 
disease. 

The  contagiosity  of  patients  suffering  from  typhoid 
fever  is  consequently  due  to  the  presence  of  the  typhoid 
bacillus  in  the  excreta,  iirine  and  vomit,  and  in  an  acces- 
sory degree  in  the  other  secretions,  including  pus  and  other 
pathological  products.  The  patients'  dejecta  constitute 
the  most  dangerous  elements  in  the  transmission  of  the 
disease. 

The  corpses  of  persons  who  have  died  of  typhoid 
fever  are,  for  an  indefinite  period,  it  is  true,  sources  of 
infection  of  the  soil  and  subsoil  water,  to  which  they 
contribute  an  enormous  quantity  of  germs.  But  it 
must  be  stated  that  this  mode  of  infection  is  limited 
owing  to  the  feeble  vitality  of  the  typhoid  bacillus  out- 
side its  natural  culture  medium,  the  human  body.  On 
the  other  hand,  we  do  not  know  of  any  animals  which 
spontaneously  contract  typhoid  fever,  which  is,  there- 
fore, a  pre-eminently  human  disease.  Moreover,  in 
the  presence  of  the  micro-organisms  of  putrefaction 
and  those  of  the  soil,  the  typhoid  bacillus  does  not 
survive  for  long.  It  dies  as  the  result  of  a  struggle  for 
life  with  the  other  bacteria.  It  is,  indeed,  a  general 
law  that  most  pathogenic  microbes,  and  especially  the 
micro-organisms,  which  are  pathogenic  for  man  ex- 
clusively, cannot  multiply  outside  the  human  body. 
Some  survive  in  this  external  medium  for  a  compara- 
tively short  time,  but  all  die  and  sometimes  very 
rapidly. 

The  result  of  this  is  that  the  contagion  of  infectious 
diseases  demands  for  its  realisation  an  assemblage  of 
conditions  which  can  easily  be  determined,  in  the 
majority  of  cases,  when  the  pathogenic  agent  can  be 


ETIOLOGY  :   DETERMINING  CAUSES         185 

cultivated  and  isolated  by  laboratory  methods.  Such 
is  the  case  in  typhoid  fever.  This  possibility  of  deter- 
mining the  presence  of  its  pathological  micro-organisms 
has  enabled  us  to  study  in  detail  another  important 
factor  in  its  transmission,  the  "  germ  carrier." 


CHAPTER  IX 

ETIOLOGY  OF   TYPHOID  FEVER   (continued) — THE  HUMAN 
FACTOR — THE  R6LE   OF  CARRIERS 

The  bacteriological  researches  which  have  been  made 
by  a  large  number  of  investigators  have  clearly  proved 
the  effective  survival  of  the  typhoid  bacillus  in  the 
patient,  in  spite  of  his  recovery  from  the  disease.  It 
has  already  been  shown  that  some  cases  of  periostitis 
or  osteitis  occurring  sometimes  even  several  years  after 
recovery  from  typhoid  fever  might  contain  the  living 
bacillus.  On  the  other  hand,  a  long  time  ago  a  certain 
number  of  French  physicians  established  the  relation 
existing  between  acute  or  chronic  biliary  infections, 
cholecystitis  or  cholelithiasis  and  the  typhoid  bacillus 
which  they  had  isolated  by  cultures  (Dupre,  Langlois, 
Gilbert  and  Foumier,  Faitout  and  Ramond,  Sacquepee, 
Carnot,  etc.). 

Epidemiological  observations  and  the  undoubted 
transmission  of  typhoid  fever  by  healthy  subjects  who 
had  had  the  disease  a  long  time  ago,  led  to  an  inquiry 
as  to  the  explanation  of  this  method  of  contagion. 

The  subject  who  has  recovered  from  typhoid  fever, 
or  from  one  of  the  atypical  forms  of  this  infection,  the 
individual  who  had  been  merely  touched,  as  it  were,  by 
the  bacillus,  but  had  nevertheless  given  it  a  shelter, 
however  brief  it  might  be,  in  his  blood,  gall-bladder, 
renal  pelvis  or  bladder,  is  not  always  freed  from  the 
infective  agent  by  the  mere  fact  of  his  recovery. 

In-  a  fairly  large  number  of  cases  the  bacillus  may 
survive  the  disease.  Clinical  recovery  does  not  mean 
bacteriological  recovery.  And  thus  we  find  the  explana- 
tion of  the  abnormal  prolongation  of  certain  epidemics, 

186 


ETIOLOGY :    THE  HUMAN  FACTOR  187 

of  "typhoid  fever  houses,"  of  cases  of  contagion  hitherto 
unexplained,  and  apparently  spontaneous  cases.  All 
are  due,  or  may  be  due,  to  the  conveyance  of  the  typhoid 
bacillus  by  bacillus  carriers. 

We  must  now  make  a  study  of  those  healthy  subjects 
who  are  unconsciously  carrying  the  pathogenic  organ- 
ism, disseminating  it  about  them  and  are  thus  becoming 
dangerous  agents  of  its  transmission. 

When  the  fseces  of  persons  recently  recovered  from 
typhoid  fever  are  grown  on  an  appropriate  medium, 
colonies  of  the  typhoid  bacillus  may  be  found  in  sqme 
of  the  specimens. 

Further  examinations  show,  though  not  invariably, 
the  persistence  of  the  bacillus  in  their  excreta.  Such 
persons  are  germ  carriers. 

The  first  researches  on  germ  carriers  were  made  by 
Remlinger  and  Schneider  in  1897  at  the  Val-de-Grace 
School.  On  examination  of  the  fseces  of  ten  soldiers 
who  had  been  treated  for  various  affections,  these 
observers  isolated  the  typhoid  bacillus  in  five  cases. 

In  a  publication  which  appeared  shortly  afterwards 
Prof.  Lemoine,  of  the  same  school,  also  found  the 
bacillus  in  the  fseces  of  a  certain  number  of  patients 
who  were  not  suffering  from  typhoid  fever,  tuberculous 
patients  in  particular.  One  of  us  also  isolated  the 
bacillus  from  the  excreta  of  a  healthy  subject  in  1893. 

In  1904  Clerc  and  Ferrari  found  the  bacillus  in  six 
out  of  thirty -two  persons  who  were  in  charge  of  typhoid 
patients. 

It  was  not  till  several  years  afterwards  that  these 
researches  were  universally  confirmed  and  demon- 
strated the  existence  of  the  bacillus  in  a  fairly  high 
number  of  "  carriers." 

In  1903  Decobert  also  drew  attention  to  the  exis- 
tence of  convalescents  from  typhoid  fever  who  showed 
the  bacilli  in  their  fseces.  He  found  the  typhoid  bacillus 
for  fifteen  to  twenty  days,  and  in  one  case  for  more 
than  a  month  after  the  temperature  had  become  normal. 

Braun  found  one  patient  in  twenty,  and  Siere  one  in 
ten,  who  still  showed  the  bacillus  in  the  fseces  after 


188    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

recovery  from  typhoid  fever.  Sacquepee  found  two 
chronic  carriers  among  eleven  patients ,  etc. 

The  origin  of  the  typhoid  bacillus  which  has  been  thus 
eliminated  in  the  faeces  is  in  the  gall  bladder. 

In  this  cavity,  where  the  bacillus  finds  a  nutritive 
medium  in  which  it  can  grow,  the  microbe  lives  and 
multiplies  and  can  be  found  long  after  recovery,  just  as, 
in  the  course  of  the  disease,  in  the  dejecta.  The  pro- 
portion of  bacilli  contained  in  the  stools  of  germ  carriers 
may  be  considerable.  Researches  made  at  the  labora- 
tory of  the  Army  Medical  Advisory  Board  show  that 
carriers  can  eliminate  daOy  from  30-190  millions  of 
bacilli  per  gramme  of  excreta. 

The  excreta  of  the  carrier  thus  become  the  efficient 
cause  of  typhoid  fever  on  every  occasion  on  which  they 
come  in  contact,  directly  or  indirectly,  with  the  healthy 
subject.  This,  is  the  explanation  of  some  persistent 
endemics,  especially  in  villages,  families,  camps,  and 
cantonments  and  trenches  in  war  time,  in  spite  of  an 
early  removal  of  the  sick,  the  disinfection  of  excreta  and 
soiled  linen,  and  the  sterilisation  of  drinking-water. 

The  bacillus  is  also  conveyed  by  persons  suffering 
from  ambulatory,  abortive  or  atypical  forms  of  typhoid 
fever  in  which  no  precautions  are  taken.  It  is  no  less 
certain  that  men  in  the  incubation  stage  or  at  the  onset 
of  typhoid  fever  are  very  dangerous  propagator's  of 
the  bacillus,  especially  in  war  time,  when  soldiers 
frequently  refuse  to  consult  the  doctor  from  a  variety 
of  motives,  whether  through  fear  of  having  their  suspi- 
cions as  to  the  nature  of  their  disease  confirmed,  or 
because  war  has  accustomed  them  to  neglect  their 
physical  sufferings,  or  because  they  are  too  proud  to 
seek  advice.  Some  men  do  not  report  themselves  sick 
until  their  strength  entirely  gives  way.  It  is  thus  that 
we  find  cases  of  acute  peritonitis,  or  of  sudden  death 
from  myocarditis  in  patients  suffering  from  typhoid 
fever. 

Convalescents  and  persons  who  have  recovered  from 
the  attack  many  years  previously  act  as  carriers  of  the 
typhoid  bacillus. 


ETIOLOGY :    THE  HUMAN  FACTOR  189 

Their  role  in  the  propagation  of  the  disease  is  not 
exclusive.  It  is  not,  however,  a  negligible  one,  and 
in  circumstances  which  we  shall  discuss  later  it  is 
predominant. 

There  are  two  groups  of  bacillus  carriers  :  the  biliary 
or  f(Ecal  carrier,  and  the  urinary  carrier.-  The  growth 
and  persistence  of  the  bacillus  in  the  urine  are  due  to 
the  same  causes  as  the  survival  of  the  typhoid  bacillus 
in  the  bile. 

German  hygienists  have  made  a  distinction  between 
"  primary  "  germ  carriers,  i.  e.  those  who  had  never 
been  ill,  and  "  secondary  "  carriers,  i.  e.  those  who  had 
previously  had  typhoid  fever.  This  distinction  has 
no  practical  interest  and,  further,  by  the  suggestion 
that  the  bacillus  has  escaped  from  the  body  without 
having  caused  a  previous  infection  of  the  blood,  however 
short-lived  and  slight  it  may  have  been,  is  not  in 
conformity  with  facts.  In  carriers  who  have  never  had 
typhoid  fever  there  is  always  a  period  of  blood  infection 
which  precedes  the  growth  in  the  gall  bladder. 

As  we  have  seen,  in  epidemic  times  individuals  are 
to  be  found  who  have  the  bacillus  in  their  blood, 
although  they  are  free  from  typhoid  fever.  Further,, 
the  serum  test  is  positive  in  a  certain  number  of  healthy 
individuals,  which  also  proves  in  another  manner  the 
reality  of  the  infection. 

We  will  now  discuss  temporary  carriers  and  chronic 
carriers. 

The  duration  of  the  persistence  of  the  typhoid  bacillus 
in  the  stools  of  germ  carriers  varies  considerably.  It 
ranges  from  a  few  weeks  to  months  or  years.  It  may 
even  continue  throughout  life. 

After  recovery  from  typhoid  fever  the  bacillus  either 
disappears  from  the  stools — the  most  frequent  event — 
or  it  may  stiU  persist  in  them.  The  proportion  of  those 
in  whom  it  persists  is  from  4  to  5  per  cent.  Park 
estimates  this  number  at  6  per  cent.  Of  these  a  third 
(2  per  cent.)  keep  the  baciUus  for  several  weeks  or  two 
to  three  months.  About  1  per  cent,  remains  a  carrier 
from  three  months  to  a  year.     Beyond  this  date  the 


190    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

number  of  chronic  carriers  is  a  little  more  than  1  per 
cent: 

The  statistics  obtained  by  examination  of  the  stools 
vary  with  the  observers.  Cases  in  which  the  bacillus 
may  be  found  in  the  excreta  for  ten,  twenty  or  thirty 
years,  and  even  longer,  are  doubtless  less  numerous,  but 
are  by  no  means  exceptional. 

The  predominance  of  typhoid  carriers  in  the  female 
sex  is  a  well  proved  but  unexplained  fact.  The  differ- 
ence between  the  two  sexes  is  considerable.  On  the 
other  hand,  the  number  of  carriers  among  children  is 
much  less  than  among  adults.  Children  aged  eighteen 
months  have  been  found  to  be  carriers. 

If  chronic  carriers  only  be  considered,  79  per  cent, 
are  women  and  21  per  cent.  men. 

A  similar  examination  made  among  children  showed 
that  4  per  cent,  were  chronic  carriers. 

Frequent  cultivation  of  the  stools  of  carriers  fairly 
often  shows  that  there  are  periods  during  which  no 
elimination  takes  place. 

This  disappearance  of  the  bacilli  Occurs  very  irregu- 
larly. Absence  of  bacilli  may  be  noted  at  the  onset 
of  convalescence,  and  their  presence  several  months 
afterwards. 

Subsequently  the  presence  of  the  typhoid  bacilli  in 
the  faeces  is  also  sometimes  continuous  and  sometimes 
intermittent. 

Intervals  of  varying  length  occur  which  may  last  one 
or  more  weeks  and  even  two  or  three  months,  followed 
by  a  return  or  even  a  considerable  increase  in  the 
number  of  bacilli  eliminated.  It  is  obvious  that  germ 
carriers  are  dangerous  during  these  periods  of  activity. 
D.  S.  Da  vies  and  Walker  Hall  have  even  thought  that 
their  period  of  contagiosity  was  related  to  the  seasons 
(from  May  to  November  in  England),  but  this  view  has 
not  been  confirmed. 

It  is  therefore  necessary  for  the  detection  of  carriers 
to  have  recourse  to  repeated  examinations  for  a  fairly 
long  period,  e.  g.  six  months  to  a  year  at  least. 

This,  it  must  be  admitted,  is  a  method  of  difficult 


ETIOLOGY :    THE  HUMAN  FACTOR  191 

application  in  a  large  community,  especially  when  one 
considers  that  the  isolation  of  the  typhoid  bacillus  from 
the  stools  requires  some  experience  owing  to  the  fre- 
quent presence  of  bacilli  of  the  paracoli  group  and 
B.  fcecalis  aljcaligenes,  which  grow  abundantly  in  the 
intestine,  and  on  superficial  examination  may  be  classed 
as  typhoid  bacilli.  The  agglutination  test  has,  there- 
fore, been  recommended,  as  it  is  positive  in  a  1  in 
100  dilution  among  three-quarters  of  the  carriers. 

Carriers  chiefly  consist  of  persons  who  have  recovered 
from  the  disease  some  time  previously.  But  it  has 
been  said  that  persons  who  have  never  had  typhoid 
fever  may  also  harbour  the  bacillus.  Their  attack  has 
been  mild  or  unrecognised  and  left  this  latent  condition 
as  a  residue. 

It  has  been  noticed  that  such  carriers  are  chiefly 
found  among  persons  who  have  been  near  typhoid 
patients,  such  as  nurses,  male  or  female  attendants, 
doctors,  and  generally  any  persons  who  have  been 
attending  them. 

Sometimes  carriers  themselves  have  been  known  to 
contract  typhoid  fever. 

The  duration  of  the  persistence  of  the  typhoid  bacillus 
in  the  gaU-bladder  varies  considerably.  Although,  as 
a  rule,  its  persistence  does  not  exceed  three  months,  a 
certain  number  of  carriers  remain  infected  and  in- 
fectious for  ten  or  twenty  years  and  even  more.  Some 
keep  and  discharge  the  bacilli  throughout  life.  Donald 
Gregg  reported  in  1908  the  case  of  a  woman  who  had 
had  typhoid  fever  in  1856,  but  had  been  in  good  health 
since,  except  for  attacks  of  migraine  accompanied  by 
diarrhoea,  and  who  still  had  the  typhoid  baciUus  in  her 
stools  after  fifty-two  years. 

These  temporary  or  chronic  carriers  thus  become  the 
starting-point  of  isolated  or  epidemic  cases,  either  in 
their  home  surroundings  or  in  places  in  which  they  may 
have  stayed  for  only  a  short  time.  They  may  transmit 
the  baciQus  by  direct  contagion  or  by  agents  of  various 
kinds. 

Carriers,  therefore,  play  an  important  part  in  the 


192    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

propagation  of  typhoid  fever.  The  modes  of  contagion 
are  obviously  similar  to  those  which  are  due  to  actual 
patients  who  are,  properly  speaking,  carriers.  There 
is,  however,  an  important  distinction  between  the  two. 
Patients  being  isolated  and  compelled  to  stay  in  bed 
cannot  by  themselves  spread  the  disease.  They  may 
directly  infect  those  who  come  near  them,  but  the 
conveyance  of  the  germ  to  the  outside  world  depends 
upon  the  fate  of  the  excreta  in  which  it  is  mixed. 
Every  object  which  has  served  for  the  personal  use  of 
the  patient  thus  becomes  an  actual  vehicle  for  the 
bacillus  (bed  linen,  basins,  etc.).  The  germ  carrier, 
on  the  other  hand,  is  not  deprived  of  movement  by 
disease,  but  goes  from  place  to  place,  and  may  take  the 
bacilli  wherever  he  deposits  his  excreta.  Patients  are 
under  close  observation,  their  condition  attracts  atten- 
tion and  involves  special  precautions  and  measures  of 
disinfection,  whereas  germ  carriers  escape  recognition. 

It  may  be  mentioned  that  the  typhoid  carrier 
does  not,  as  a  rule,  excrete  so  large  a  number  of 
bacilli  as  the  typhoid  patient,  except  during  periods  of 
diarrhoea,  in  which  the  amount  is  considerable.  Some 
carriers,  however,  have  unintermittently  an  enormous 
quantity  of  bacilli  in  their  stools  and  in  almost  pure 
culture. 

It  has  been  urged  that  the  bacilli  discharged  by  germ 
carriers  are  less  virulent  and  less  active  than  those 
eliminated  by  the  patients.  This  hypothesis  is  not 
verified  by  facts.  Numerous  family  epidemics  which 
have  been  caused  by  the  direct  contagion  of  germ 
carriers  have  given  rise  to  fatal  cases. 

The  foregoing  remarks  apply  also  to  urinary  carriers. 

The  persistence  of  bacilluria  after  recovery  from 
typhoid  fever  is  from  a  few  weeks  to  several  months 
or  several  years  (Youdalewitch,  Wright  and  Semple, 
Richardson,  H.  Vincent).  Contagion  by  urinary  germ 
carriers,  however,  is  less  frequent  and  important  than 
by  carriers  of  biliary  origin. 

Instances  of  contagion  due  to  both  have  been  quoted 
in  every  country. 


ETIOLOGY :    THE  HUMAN  FACTOR  193 

It  has  been  observed  that  epidemics  or  endemics 
recur,  sometimes  every  year,  in  the  immediate  neigh- 
bourhood of  germ  carriers. 

Among  the  histories  of  epidemics  published,  one  of 
the  best  known  is  that  observed  in  1907  by  Dr.  Soper, 
Medical  Officer  of  Health  for  the  City  of  Boston.  A 
cook  who  had  had  typhoid  fever  in  1900  gave  rise  to 
thirty-eight  cases  of  typhoid  fever  in  the  various 
families  in  which  she  had  successively  been  employed 
since  her  recovery. 

D.  Gregg's  case,  who  had  had  typhoid  fever  in  1856, 
gave  rise  to  seven  cases  of  the  same  disease  in'  her 
immediate  surroundings  between  1905  and  1908,  or 
fifty -two  years  after  her  infection. 

Huggenberg  has  recorded  the  case  of  a  woman  in 
Central  Switzerland  who  had  had  typhoid  fever  thirty- 
one  years  before  and  still  presented  bacilluria.  She 
had  transmitted  typhoid  fever  to  her  husband  in  1886, 
to  her  son  in  1892,  to  four  servants  from  1899  to  1902, 
to  her  daughter-in-law  shortly  after  coming  to  live  with 
her,  and  in  1903  to  1905  to  four  other  servants.  In 
1908  a  fresh  case  of  contagion  was  found  in  a  servant. 
No  case  occurred  in  her  immediate  surroundings  be- 
tween 1905  and  1908,  but  at  that  date  her  servants 
were  already  infected. 

W.  Park,  Director  of  the  New  York  Department  of 
Health,  has  published  a  very  similar  case  to  that  of 
Soper. 

The  case  was  that  of  a  cook,  who  declared  that  she 
had  never  had  typhoid  fever.  She  nevertheless  caused 
an  outbreak  of  typhoid  fever  in  seven  of  the  eight 
different  families  in  which  she  was  successively  em- 
ployed. The  total  number  of  cases  to  which  she  thus 
gave  rise  was  as  high  as  twenty -eight. 

Her  blood  agglutinated  the  typhoid  bacillus,  which 
was  also  found  in  the  excreta.  She  had  to  be  isolated 
in  the  North  Brothers  Island  Hospital. 

In  the  Report  on  Epidemics  to  the  French  Home 
Oflice,  H.  Vincent  (Academic  de  Medecine,  1909)  re- 
corded some  cases  of  contagion  due  to  carriers,  sick 


194    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

and  otherwise.     Direct  contagion  from  man  to  man  is 
the  rule  in  the  country. 

At  Castelfranc,  a  village  of  463  inhabitants,  in  the 
Lot  Department,  a  girl  aged  ten,  who  had  come  from 
another  village  in  which  there  was  an  epidemic  caused 
by  the  water,  infected  six  living  in  her  house  or 
neighbouring  houses. 

In  Cevan  a  young  child,  who  had  been  infected  in 
another  village  by  her  nurse,  gave  rise  to  six  cases. 
The  child  of  the  new  nurse,  three  brothers  and  sisters, 
the  nurse's  mother  and  servant  were  infected  in 
succession. 

Courtois-Suffit  and  Beaufume  have  published  the 
account  of  an  epidemic  transmitted  by  a  germ  carrier^ 
After  her  arrival  in  a  village  in  the  Yonne  Department 
she  gave  the  disease  to  fourteen  persons  in  her  family 
or  in  the  neighbouring  houses. 

Numerous  descriptions  have  been  published  of 
epidemics  due  to  germ  carrriers  in  schools,  seminaries 
and  lunatic  asylums.  The  army  is  not  exempt.  Netter 
recorded  the  outbreak  of  twenty -one  cases  which  oc- 
curred without  obvious  reasons  in  one  out  of  three 
batteries  in  a  garrison  in  the  East  of  France. 

The  food  and  water  supply  were  common  to  the  three 
batteries,  moreover  the  drinking  water  was  sterilised. 
But  the  infected  battery  contained  a  young  soldier  who 
had  had  typhoid  fever  seven  years  previously  and  whose 
stools  contained  numerous  bacilli. 

The  same  author  has  also  given  an  account  of  an 
epidemic  on  board  a  Japanese  man-of-war,  due  to  two 
carriers.  When  these  had  been  isolated,  the  epidemic 
disappeared. 

In  1908  a  certain  number  of  cases  of  typhoid  fever 
having  occurred  at  Aldershot  Camp,  without  obvious 
cause,  all  the  men  were  examined.  One  of  them  had 
bacilli  in  the  urine.  He  had  contracted  typhoid  fever 
in  Aden  in  1904.  He  was  isolated  and  the  epidemic 
ceased . 

In  August  1901  a  young  soldier,  who  had  typhoid 
fever   three   months    previously,    arrived   in    England 


ETIOLOGY :    THE  HUMAN  FACTOR  195 

from  South  Africa.  A  fortnight  later  three  sisters 
and  two  brothers  of  the  patient,  a  young  servant, 
the  cook,  a  friend  and  two  persons  living  in  the  next 
house  were  attacked  in  succession.  The  young  sol- 
dier's urine  contained  175  bacilli  per  c.c.  The  infec- 
tion had  occurred  as  the  result  of  the  well  water, 
which  communicated  with  the  water  closet. 

The  attention  of  English  doctors  in  India  has  been 
directed  to  typhoid  bacillus  carriers. 

Typhoid  fever  was  very  frequent  among  the  troops, 
since  prior  to  the  adoption  of  preventive  inoculation 
there  were  at  least  1000  cases  yearly  (not  including 
the  much  rarer  cases  of  paratyphoid  fevers  A  and  B), 
with  the  result  that  every  year  germ  carriers  were  left 
to  carry  on  the  disease. 

For  this  reason  ever  since  1908  convalescents  from 
typhoid  fever  are  sent  to  the  special  depot  at  Naini- 
Tal,  which  is  isolated  and  provided  with  a  disinfecting 
apparatus  and  a  laboratory.  The  urine  and  faeces  are 
examined  there  every  week,  and  patients  who  have 
recovered  from  typhoid  fever  are  kept  here  for  four 
months. 

Most  of  the  men  keep  the  bacilli  in  their  stools  for 
a  few  weeks  only.  Chronic  carriers,  i.  e.  those  who 
keep  the  bacillus  for  six  months,  are  discharged  from 
the  service.  Their  proportion  has  been  3  per  cent. 
After  the  first  year  (1908)  a  drop  of  9  per  cent,  was 
observed  in  the  incidence  of  typhoid  fever  among  the 
units  in  which  these  precautions  had  been  taken, 
while  the  others  showed  an  increase  of  26  per  cent. 

In  a  new  Parliamentary  Report  (December  25, 
1909)  it  was  noted  that  the  duration  of  the  persistence 
of  the  bacillus  necessitating  discharge  from  the  service 
had  been  lowered  to  three  months.  At  the  end  of 
this  time  the  man  is  discharged,  unless  he  prefers  to 
remain  in  hospital.  The  Medical  Officer  of  Health  for 
the  district  to  which  he  goes  on  discharge  from  the 
service  is  notified  of  the  case.  It  is  to  be  feared  that 
these  carriers  on  return  to  civil  life  may  become  the 
starting-point  of  an  epidemic. 


196    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Questions  were  raised  in  the  House  of  Commons  on 
the  subject  of  soldier  carriers  who  had  been  sent 
home  from  India  and  isolated  at  Millbank  Military 
Hospital. 

Public  authorities  have  everywhere  been  much  con- 
cerned about  the  danger  likely  to  result  from  these 
carriers,  owing  to  the  absence  of  help  hitherto  afforded 
by  prophylaxis.  In  France  this  problem  has  been 
studied  by  the  Health  Service  of  the  army,  and  gave 
rise  in  1910  to  an  important  discussion  at  the  Academy 
of  Medicine.  In  England,  Germany,  Russia,  Belgium, 
and  the  United  States,  especially  at  the  State  Board  of 
Health  of  Iowa,  sanitary  legislation  has  endeavoured 
to  find  a  remedy  for  the  conveyance  and  propagation 
of  typhoid  fever  by  these  carriers,  but  this  special 
prophylaxis  meets  with  very  great  difi&culties,  as  may 
well  be  understood. 

Families  and  persons  living  in  immediate  contact 
with  the  carrier  are  most  exposed  to  the  risk  of  con- 
tagion. Life  in  common  leads,  indeed,  sooner  or 
later,  to  direct  or  indirect  conveyance  of  the  bdcillus 
to  other  persons. 

It  is,  therefore,  in  poor  families,  in  working-class 
households,  or  in  the  country  that  contagion  due  to 
carriers  has  most  chance  of  developing. 

In  the  army  the  role  of  typhoid  (or  paratyphoid) 
carriers  in  time  of  peace  is  certainly  limited  to  a  few 
special  cases.  But  it  becomes  considerably  more  im- 
portant in  camps,  and  especially  in  war  time,  when 
the  crowding  together  of  a  considerable  number  of 
effectives  results  in  the  soil  being  saturated  with  human 
excreta. 

The  chances  of  infection  are  thereby  extraordinarily 
multiplied,  especially  when  associated  with  even  more 
important  factors,  such  as  the  presence  of  those  who 
are  really  suffering  from  the  disease,  both  those  who 
are  under  treatment,  and  still  more  so  those  who  are 
not,  e.  g.  soldiers  in  the  incubation  period  and  at  the 
onset  of  typhoid  fever,  as  well  as  those  who  have 
only  an  incomplete  form  of  the  disease.     We   have 


ETIOLOGY :    TEE  HUMAN  FACTOR  197 

thus  an  explanation  of  the  disastrous  intensity  of  the 
epidemics  by  which  armies  were  formerly  ravaged 
during  even  the  shortest  wars. 

We  have  now  to  discuss  those  circumstances  that 
favour  epidemic  contagion.  After  having  studied  the 
sources  jrom  which  the  typhoid  bacillus  comes,  we 
must  state  whither  it  goes. 


CHAPTER   X 

THE   PRINCIPAL   MODES   OF   DIRECT   TRANSMISSION    OF 
THE   TYPHOID    BACILLUS 

After  leaving  the  patient  or  the  carrier,  the  'patlio- 
genic  haciUus  of  typhoid  fever  follows  the  path  of  the 
excreta  and  pathological  products  in  which  it  is  incor- 
porated. When  it  comes  in  contact  with  a  susceptible 
person  the  micro-organism  can  exercise  its  infective 
power  either  in  the  immediate  surromidings  of  the 
patient  or  carrier,  or  at  a  distance  from  its  original 
focus. 

The  bacillus  makes  its  way  into  the  system  either 
by  direct  or  indirect  contagion.  The  digestive  tract 
is  almost  always  the  portal  of  entry.  How  does  the 
infective  agent  gain  admission  ? 

The  simplest  mode  of  transmission  is  by  direct 
contagion.  Whether  eliminated  by  a  patient  or  a 
carrier,  the  micro-organism  is,  as  a  rule,  communi- 
cated without  any  intermediary  agent  to  persons  in 
their  immediate  surroundings,  such  as  relations, 
doctors,  nurses,  visitors,  patients  in  the  next  bed,  etc. 

This  direct  contagiosity  of  typhoid  fever  was  well 
known  to  the  old  observers,  such  as  Louis,  Grendron 
and  Piedvache.  On  meeting  with  successive  cases  in 
the  same  family  which  were  undoubtedly  connected 
with  one  another,  Louis,  at  the  beginning  of  the 
nineteenth  century,  declared  that  typhoid  fever  was 
certainly  contagious,  at  least  in  the  country.  In- 
sufficient hygienic  precautions,  absence  of  cleanliness, 
the  non -disinfection  of  excreta,  and  soiled  linen  fur- 
nish an  explanation  of  this  transmission  of  the 
micro-organism. 

198 


DIRECT  TRANSMISSION  OF  THE  BACILLUS    199 

Direct  contagion  most  frequently  takes  place  when 
the  patient  is  being  attended  to  in  connection  with 
defsecation  or  micturition,  the.  change  of  body  linen 
or  bedclothes,  or  when  he  is  being  carried  to  the  bath. 

It  may  also  occur  when  he  is  given  a  drink,  or  his 
mouth  and  teeth  are  being  cleansed,  or  a  visitor 
shakes  his  hand  which  has  been  contaminated.  Con- 
tagion occurring  in  hospitals,  as  a  rule,  is  due  to  these 
factors.  Numerous  cases  are  recorded  in  which 
patients  have  been  infected  by  offering  their  services 
to  a  typhoid  patient  in  the  next  bed. 

The  carrier  may  directly  transmit  the  germ  in  the 
same  manner  whenever  he  is  suffering  from  a  disease 
which  requires  similar  attention,  whatever  its  nature 
may  happen  to  be.  Likewise  the  patient  who  is 
suffering  from  suppuration  due  to  the  typhoid  bacillus, 
or  has  been  operated  on  for  typhoid  cholecystitis,  etc., 
may  transmit  the  disease  to  an  attendant  who  does 
not  take  proper  precautions. 

On  the  other  hand,  the  contagion  may  be  conveyed 
by  a  male  or  female  attendant,  who  is  a  carrier,  to 
children  or  adults  suffering  from  another  infection. 
Uncleanliness  is,  indeed,  almost  always  at  the  root  of 
direct  contagion.  Furthermore,  whatever  the  means 
by  which  the  contagion  takes  place,  the  hands  are, 
after  all,  the  receptive  organs  and  transmitting  agents  of 
the  typhoid  bacillus.  The  hands  are  contaminated  by 
the  particles  of  faeces,  drops  of  the  patient's  urine, 
vomit,  sputa,  etc.,  and  without  being  washed  collect 
and  convey  the  food  to  the  mouth.  For  this  reason 
it  has  been  rightly  said  that,  whatever  may  be  the 
origin  of  the  bacillus,  whether  from  a  patient  or  a 
carrier,  typhoid  fever  by  contact  is  a  disease  caused  by 
unclean  hands  (H.  Vincent).  This  statement  is  further 
confirmed  by  the  fact  that  it  is  the  carrier's  unclean 
hand  which  manipulates  the  food,  contaminates  it  with 
bacilli,  and  so  passes  it  on  to  other  persons  about  him. 

The  denomination  of  "  epidemic  by  contact  "  has 
been  given  in  Germany  to  those  cases  of  typhoid  fever 
which  occur  in  the  immediate  neighbourhood  of  the 


200    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

patient  or  carrier.  This  expression  is  incorrect,  for  it 
includes  at  once  direct  and  indirect  contagion.  It 
should  be  reserved  for  those  cases  in  which  the  con- 
veyance of  the  bacillus  takes  place  directly  by  contact 
of  the  patient  with  a  healthy  subject. 

From  this  point  of  view  direct  contagion  occurs  in 
barracks  only  under  exceptional  circumstances,  having 
regard  to  the  other  and  undoubtedly  more  numerous 
risks  of  infection  to  which  the  soldier  is  exposed  in 
peace  time. 

The  danger  of  the  germ  carrier  mainly  depends  on 
the  mode  of  life  of  the  carrier  himself  and  of  those 
with  whom  he  lives.  Investigations  made  at  thermal 
stations  like  Vichy,  which  are  the  resort  of  patients 
suffering  from  chronic  hepatic  affections  and  of  active 
germ -carriers,  have  undoubtedly  proved  the  extreme 
rarity  of  contaminations  due  to  carriers.  The  fact  is 
that  the  spread  of  the  contagion  of  typhoid  fever 
among  neighbours  is  by  no  means  comparable  to  that 
of  some  other  diseases,  such  as  diphtheria,  cerebro- 
spinal meningitis,  the  eruptive  fevers,  mumps,  etc. 
Whereas  in  the  latter  infections  direct  contagion  plays 
the  principal,  preponderating,  and  even,  in  some 
diseases,  exclusive  part,  the  same  cannot  be  said  of 
typhoid  fever. 

In  the  carrier  the  typhoid  bacillus,  instead  of  being 
in  direct  and  immediate  contact  with  the  outer  air,  is 
hidden  in  the  gall-bladder  and  intestine,  or  in  the 
bladder.  It  is  eliminated  .intermittently  and  mixed 
with  the  faeces  or  urine.  The  result  is  that  the  con- 
ditions are  less  suitable  for  its  reaching  the  outer 
world  and  for  directly  infecting  the  persons  in  the 
immediate  vicinity.  Such  infection  could  only  occur 
if  the  bacillus  had  its  habitat  in  the  carrier's  saliva  or 
nasal  or  pharyngeal  mucus,  which  is  not  the  case. 

Consequently,  direct  contagion  by  the  typhoid  bacillus 
is  restricted  to  well-defined  conditions.  It  can  only 
occur  when  particles  of  faeces  or  urine,  conveyed  by 
unclean  hands  or  by  bedpans  or  urine -bottles,  are 
deposited  on  food,  bread,  etc. 


DIRECT   TRANSMISSION  OF  THE  BACILLUS    201 

The  result  is  that,  however  important  contact  may- 
be in  the  transmission  of  the  bacillus  discharged  by 
germ  carriers,  the  conditions  which  give  rise  to  direct 
contagion  are  not  very  frequent. 

Consequently,  transmission  by  indirect  contagion  is 
much  more  important. 

From  the  foregoing  remarks  it  emerges  that  the  role 
of  carriers  in  the  transmission  of  typhoid  fever  cannot 
be  accurately  defined,  but  that  it  is  much  more 
restricted  than  German  hygienists  maintain. 

It  is  very  difficult  to  get  definite  statistics  on  this 
subject.  Some  writers  hold  that  contact  with  chronic 
carriers  accounted  for  30  per  cent,  of  cases  of  typhoid 
fever;  others  for  only  2  to  5  per  cent.,  6  per  cent. 
(Park),  etc. 

But  in  all  epidemics,  especially  in  those  of  prolonged 
duration,  every  cause  of  contagion,  direct  or  indirect,  is 
given  full  play,  and  thus  it  is  often  impossible  to  in- 
criminate one  cause  more  than  another  in  the  presence 
of  such  varied  etiological  factors. 

A  second  conclusion  to  be  drawn  from  our  discus- 
sion is  that  among  the  chronic  carriers  of  the  typhoid 
bacillus  the  most  dangerous  are  those  ivho  are  engaged 
in  trades  connected  loith  the  preparation  of  food. 

On  perusal  of  the  cases  of  typhoid  contagion  due  to 
carriers,  one  is  struck  by  the  high  number  of  instances 
in  which  male  or  female  cooks  are  concerned,  as  well 
as  women  in  charge  of  the  preparation  of  food,  milk- 
ing, etc.  Waiters  or  servants  in  a  restaurant,  pastry- 
cooks, grocers,  gardeners,  and  men  or  women  em- 
ployed on  farms  or  dairies  are  some  of  the  most 
dangerous  carriers. 

Women  especially,  as  we  have  already  said,  have 
been  found  to  be  the  most  numerous  among  the 
carriers.  In  house  epidemics,  therefore,  when  the 
drinldng  water  is  wholesome,  one  must  "  look  for  the 
woman,"  as,  owing  to  her  occupation  and  domestic 
habits,  she  is  accustomed  to  handling  articles  of  food 
which  are  consumed  raw  and  not  heated. 

Contagion    of    this    kind    requires    an    absolute    or 


202    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

relative  lack  of  cleanliness,  and  the  faecal  contamina- 
tion of  the  carriers'  fingers  and  hands. 

In  the  army  contagion  from  man  to  man  by  germ 
carriers  also  furnishes  an  explanation  of  certain  cases 
of  typhoid  fever. 

Instances  have  been  quoted  in  the  French  army, 
but  they  are  more  frequent  in  foreign  armies,  especially 
the  English  army  in  India.  Strange  to  say,  although 
attention  has  long  been  directed  to  the  possible  role 
of  chronic  carriers,  cases  due  to  this  mode  of  infection 
remain  rare  in  barracks  in  peace  time.  For  various 
reasons  direct  contagion  is  also  uncommon.  The 
proof  of  this  is  to  be  found  in  the  numerous  examples 
of  a  solitary  isolated  case  of  typhoid  fever  occurring 
in  a  barracks  and  not  followed  by  any  other  cases. 
Besides,  if  carriers  played  a  preponderant  part,  both 
in  the  army  and  the  civil  population,  how  are  we  to 
explain  the  seasonal  course  of  the  disease,  its  frequency 
from  July  to  October,  and  its  rarity  or  absence  in  the 
cold  season  ?  How  are  we  to  explain  the  fact  that  in 
the  army  the  garrisons  in  the  north  of  France  are 
almost  always  free  from  typhoid  fever,  whereas  those 
in  the  south,  on  the  contrary,  have  numerous  cases  of 
this  disease  ?  The  germ  carriers,  however,  consisting 
of  men  who  have  formerly  had  typhoid  fever  and  v/ho 
still  retain  their  bacilli,  have  been  distributed  indis- 
criminately in  both  these  areas,  and  their  influence 
should  make  itself  felt  in  every  season. 

Consequently,  in  the  army  in  peace  time  contagion, 
due  to  carriers,  is  most  to  be  feared  when  some  of  these 
carriers  are  to  be  found  among  the  cooks  or  cooks' 
assistants,  or  among  those  in  charge  of  filters  or 
apparatus  for  sterilising  water,  the  canteen  women, 
etc. 

Apart  from  these  special  cases,  it  may  be  admitted 
that  the  shaking  of  hands,  and  use  of  spoons,  forks  or 
cups  which  have  been  touched  by  the  unclean  hands 
of  carriers,  may  disseminate  the  bacillus,  but  such 
cases,  on  close  examination,  are  infrequent. 

On  the  other  hand — and  we  cannot  insist  too  much 


DIRECT  TRANSMISSION  OF  THE  BACILLUS    203 

on  this  point — contagion  caused  by  temporary  or 
chronic  carriers  finds  the  most  propitious  occasions  in 
war  time,  when  neither  faeces  lor  urine  are  confined 
to  latrines,  or  washed  into  tht.  sewers,  or  kept  in  pails 
or  water-tight  pits. 

In  spite  of  severe  orders  and  constant  watching, 
human  excrement  is  to  be  found  everywhere — on  the 
ground,  in  cantonments,  gardens  and  lanes,  on  the 
edges  or  in  the  bottom  of  ditches  and  in  the  fields — 
and  from  these  sources  the  bacillus  finds  its  way  to 
man. 

Whatever  its  original  source,  whether  a  person  in 
the  incubation  stage,  a  patient  at  the  onset  of  the 
disease,  or  with  an  abortive,  mild  or  ambulatory 
attack,  or,  lastly,  a  convalescent  or  a  chronic  carrier, 
the  conveyance  of  the  bacillus  to  the  healthy  man  is 
brought  about  in  such  a  case  by  very  varied  agencies. 

It  is  these  agencies  which  we  shall  now  discuss. 


CHAPTER   XI 

INDIRECT     CONTAGION     BY     PATIENTS     OR     CARRIERS 

INERT     FACTORS     IN     THE     TRANSMISSION     OF     THE 
TYPHOID    BACILLUS 

In  the  hierarchy  of  the  factors  of  contagion  which 
enter  into  the  etiology  of  typhoid  fever,  it  is  not  per- 
missible to  dethrone  some  at  the  expense  of  others. 
It  is  certainly  due  to  an  excessive  abuse  of  the  Grerman 
doctrine,  which  in  itself  is  exaggerated,  that  such 
important  agencies  as  drinking-water,  j9ies,  etc.,  were 
denied  their  proper  share  in  the  transmission  of  the 
typhoid  baciUus. 

The  bacillus,  from  whatever  source  it  may  come,  is 
carried  away  with  the  fceces  and  urine,  and  accompanies 
them  wherever  they  go.  When  discharged  outside  the 
body,  it  does  not  find  the  conditions  to  enable  it  to 
live  and  grow  which  existed  in  its  human  medium. 
The  soil,  the  air  in  which  it  is  mixed  with  dust,  water, 
vegetables,  animals  and  clothes  serve  to  protect  it. 
The  duration  of  its  vitality  in  such  an  environment 
has  formed  the  object  of  numerous  researches,  which 
show  little  agreement  with  one  another  and  are 
sometimes  divergent. 

These  differences  can  be  explained  by  the  fact  that, 
owing  to  the  difficulty  of  isolating  typhoid  bacilli, 
many  observers  have  worked  with  pure  cultures  in 
the  presence  of  sterilised  earth,  water,  etc.,  thus  per- 
forming experiments  which  in  no  way  correspond  to 
natural  conditions.  Other  writers  may  have  confused 
the  typhoid  bacillus  with  some  other  bacteria  (paracoli 
bacilli,  or  B.  fcecalis  alkaligene^),  which  are  common 
in  fseces,  manure,  dung-heaps,  and  putrefjdng  organic 
matter. 

204 


INDIRECT  CONTAGION  205 

Lastly,  these  investigations  were  made  for  the  most 
part  at  a  time  when  the  differential  characters  of  cul- 
tures on  sugar  media,  neutral  red  agar,  etc.,  had  not 
yet  been  determined. 

We  can,  therefore,  perhaps  attribute  only  a  relative 
value  to  researches  on  the  vitality  of  the  typhoid 
bacillus  outside  the  human  body. 

The  average  period  during  which  the  bacillus  sur- 
vives in  faeces  and  water-closets  is  from  twenty-five  or 
thirty  days  to  five  months  (Galvagno  and  Caldefini) ; 
in  the  soil  five  months  (Grancher  and  Deschamps) ;  in 
sand,  street  or  house  dust,  and  dry  sawdust  one  to 
two  months ;  in  buried  corpses  fifteen  to  twenty  days 
according  to  some  observers,  ninety-three  according 
to  others,  etc. 

All  these  investigations  undoubtedly  require  revision, 
because  the  typhoid  bacillus  is  very  fastidious  in  its 
conditions  of  existence,  and  does  not  live  long  in  the 
presence  of  ordinary  micro-organisms. 

It  has  been  easier  to  study  the  influence  of  heat,  cold 
and  light  on  the  typhoid  bacillus. 

It  is  killed  instantly  by  boiling.  At  a  temperature 
of  57  to  60°  C.  it  is  killed  in  an  hour,  but  not,  as  a 
rule,  after  exposure  for  the  same  time  to  a  temperature 
of  53°  C. 

When  exposed  to  the  action  of  the  sun  on  dried 
earth  it  is  killed  in  five  to  eight  hours  ;  porous  or  sandy 
soil  is  more  favourable  for  its  destruction.  On  cotton 
or  linen  exposed  to  direct  sunlight  it  survives  for 
from  two  to  twenty -six  hours ;  on  black  cloth  from 
nine  to  eleven  hours  (H.  Vincent). 

The  natural  bactericidal  action  of  the  sun  on  the 
typhoid  bacillus  is,  therefore,  well  established. 

When  deposited  on  linen,  clothes,  etc.,  the  typhoid 
bacillus  survives  for  a  comparatively  short  time,  but 
sufficiently  long,  however,  to  produce  contagion. 

Clothes,  such  as  sheets,  drawers  or  bedclothes, 
which  have  been  soiled  by  a  typhoid  patient  or  germ 
carrier  can  infect  persons  who  have  to  handle  them, 
such  as  servants,  and  especially  laundrywomen.     Cases 


206    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

of  typhoid  fever  were  formerly  common  among  hospital 
lamidry  women. 

Cases  are  on  record  of  contagion  taking  place  from 
the  wearing  of  infected  clothing.  Mortchrowski  has 
related  the  case  of  a  reservist  who  contracted  typhoid 
fever  from  wearing  the  shirt  of  another  soldier  who 
was  suffering  from  this  disease. 

Thus  clothes  and  boots  and  shoes  worn  by  a  typhoid 
patient  or  a  carrier  and  contaminated  by  faecal  matter 
can  infect  a  healthy  subject.  The  typhoid  bacillus 
persists  from  ten  days  to  four  months  in  books,  but 
is  killed  in  twelve  to  twenty-four  hours  if  exposed  to 
the  light  of  the  sun  (Laubach  of  Baltimore).  This 
mode  of  contagion  by  books  is  probably  very  rare. 

Contagion  of  the  soil  by  specific  excreta  is  very 
common,  especially  in  the  country,  where  the  general 
rules  of  hygiene  are  so  often  neglected. 

In  towns  removal  of  fsecal  matter  is  usually  carried 
out  perfectly  when  a  drainage  system  exists,  but  im- 
perfectly when  the  faeces  are  collected  in  leaking  cess- 
pits or  pails.  In  the  last  two  cases  they  remain 
harmful,  and  the  bacillus  which  they  contain  may 
find  opportunity  for  passing  through  into  the  soil  or 
reaching  man  by  the  agency  of  flies. 

Removal  of  excreta  into  the  street  presents  the 
gravest  dangers.  This  method  is  practised  in  some 
badly  supervised  towns,  in  the  suburbs  of  some  large 
towns,  and  some  workmen's  dwellings.  All  who  pass 
by  get  infected  particles  caught  on  their  boots,  take 
them  into  the  house  and  contaminate  their  hands. 

Children,  owing  to  their  practice  of  defsecating 
everywhere,  are  the  chief  propagators  of  this  street 
pollution. 

In  the  country  the  contamination  of  the  soil  by 
fsecal  matter  is  continually  occurring.  The  excreta 
of  patients  or  carriers  are  often  deposited  in  front  of 
the  door,  in  the  vegetable  garden,  or  on  the  dung- 
heap.  Removal  of  the  house  refuse  into  the  street  or 
gutter  is  commonly  practised.  The  specific  contami- 
nation of  the  soil  by  the  typhoid  bacillus  finds  its  way 


INDIRECT  CONTAGION  207 

back  to  man  by  the  agents  already  mentioned,  viz. 
boots,  clogs,  bare  feet,  hands,  vegetables,  drinking- 
water,  etc. 

In  barracks  we  find  a  possibility  of  indirect  faecal 
contagion  by  the  latrines.  They  are  often  in  a  dirty 
state,  and  when  a  man  goes  to  relieve  himself  he  risks 
contaminating  his  boots  by  the  side  of  the  latrine. 

Camps  and  cantonments,  both  in  war  and  peace, 
provide  the  same  opportunities  for  infection.  If  the 
soldiers,  as  frequently  happens,  deposit  their  excre- 
ment not  in  the  faecal  trench  but  near  it,  and  in  addi- 
tion to  this  the  rain  soaks  the  soil,  every  visit  to  the 
faecal  trench  is  the  occasion  for  a  more  or  less  dangerous 
"  microbial  foot-bath."  The  habit  which  soldiers  have 
of  cleaning  their  boots  with  pieces  of  wood,  or  even 
with  their  knife,  exposes  them  to  specific  contamina- 
tion of  their  hands,  especially  the  parts  beneath  their 
nails  and  between  their  fingers. 

In  camps  and  cantonments  human  excreta  are  only 
too  frequently  found  near  tents,  barracks,  houses,  or 
in  gardens. 

War  always  remains  the  gravest  efficient  cause  of 
this  soil  contamination,  which  almost  invariably  finds 
its  way  back  to  man. 

The  earth  returns  with  usury  the  pollution  which  it 
has  received.  The  straw  used  for  the  beds  and  the 
blankets  are  also  contaminated.  Pollution  of  the  soil 
by  specific  faecal  matter  was  incriminated  by  Surgeon- 
General  Derby,  in  the  War  of  Secession ;  the  troops 
occupying  the  camps  abandoned  by  the  Confederates 
contracted  typhoid  fever.  The  same  cause  was  in- 
voked in  the  war  in  Tunis  ;  during  the  Kusso -Turkish 
War,  the  atmosphere  was  sometimes  rendered  intoler- 
able by  the  stench  of  the  faecal  matter  accumulated 
in  the  Turkish  camps.  At  the  time  of  the  English 
Expedition  to  Egypt,  the  Medical  Officers  also  lioted 
the  incredible  filth  of  the  abandoned  Turkish  camps. 

During  the  South  African  War  the  extreme  frequency 
of  typhoid  fever  was  explained  by  this  same  injurious 
influence  of  the  soil,  infection  being  attributed  to  the 


208    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

inhaling  and  swallowing  of  faecal  dust  containing  the 
typhoid  bacillus. 

A  similar  cause  was  invoked  by  the  principal  Medical 
Officer,  Millet,  during  a  very  severe  epidemic  in  1895 
among  the  14th  and  15th  Regiments  of  Dragoons 
during  their  manoeuvres  near  Rheims  on  a  dried-up 
plain  covered  with  manure. 

It  is  obvious  that  a  recently  dried  typhoid  bacillus 
may  give  rise  to  such  infections  if  it  preserves  its 
vitality. 

But  at  the  present  time  only  a  very  restricted  role 
is  attributed  to  this  method  of  contagion.  Some  even 
deny  it  altogether. 

Much  more  important  is  infection  of  alimentary 
origin,  both  bj''  solids  and  still  more  so  by  fluids. 

Typhoid  fever  which  is  accompanied  by  a  discharge 
of  excreta  which  are  sometimes  very  rich  in  bacilli, 
readily  leads  to  contamination  of  food  substances  by 
the  patient  or  the  carrier. 

We  have  already  discussed  the  contamination  of 
food  by  unclean  hands,  and  the  conveyance  of  the 
typhoid  bacillus  into  the  alimentary  canal  of  the 
healthy  subject.  The  gathering'  of  vegetables  eaten 
raw  (salad,  radishes),  the  picking  of  strawberries  or 
raspberries,  and  of  fruit  generally,  by  similarly  con- 
taminated hands,  the  preparation  of  meals,  etc.,  all 
serve  as  occasions  for  depositing  the  typhoid  bacillus 
in  food. 

There  is  another  mode  of  contagion  by  vegetables, 
which  is  due  to  their  being  planted  in  a  soil  which 
has  been  manured  with  human  dung,  or  has  been 
watered  with  a  mixture  of  faecal  matter  and  urine. 

This  is  a  deplorable  practice,  borrowed  from  the 
Chinese,  which  is  the  cause  of  numerous  epidemic 
cases.  The  growing  of  cress  in  water  similarly  con- 
taminated also  offers  grave  dangers*.  In  numerous 
countries  the  surface  disposal  of  faecal  matter  is  carried 
out  in  a  systematic  manner;  and  this  dangerous 
commodity  is  ladled  out  over  the  vegetables  and  the 
soil. 


INDIRECT  CONTAGION  209 

Examples  have  been  quoted  of  epidemics  due  to 
the  use  of  vegetables  thus  contaminated.  In  1909 
several  cases  of  typhoid  fever  due  to  the  consumption 
of  raw  vegetables  were  seen  in  the  garrison  at  Vannes. 
The  farmer  who  provided  the  vegetables  was  in  the 
habit  of  watering  them  with  the  fsecal  matter  of  his 
daughter,  who  was  suffering  from  typhoid  fever  ! 

Unlike  paratyphoid,  which  may  affect  animals, 
typhoid  fever,  being  a  disease  confined  to  the  human 
race,  cannot  be  transmitted  by  meat,  or  only  indirectly, 
^^  e.  if  the  meat  after  it  has  been  cooked  has  been 
contaminated  by  the  cook's  hands  or  by  flies. 

On  the  other  hand,  oysters  have  been  blamed,  not 
without  reason,  for  spreading  typhoid  fever.  When 
they  have  been  collected  in  the  open  sea,  oysters  are 
perfectly  wholesome.  It  is  by  no  means  the  same  when 
their  park  is  close  to  a  harbour,  and  especially  when 
they  are  laid  close  to  sewer  mouths  and  salt-marshes 
into  which  drain  the  residuary  water  of  towns  and 
villages,  and  with  it  the  faecal  matter  of  typhoid 
patients  and  carriers.  Johnston -La  vis,  Netter,  Chante- 
messe,  Mosny,  Remlinger,  etc.,  have  insisted  upon  this 
important  cause  of  typhoid  or  paratyphoid  fevers. 

Netter  has  published  striking  examples  of  cases  of 
typhoid  fever  in  families  or  towns  in  which  Cette 
oysters  had  been  eaten.  Similar  cases  have  become  so 
numerous  that  there  is  no  need  to  mention  them. 

The  increasing  number  of  epidemics  due  to  oysters 
is  a  striking  occurrence. 

In  1907  numerous  cases  due  to  the  consumption  of 
Cancale  oysters  were  reported  at  Arras.  Infection 
due  to  oysters  also  occurred  at  Abbeville,  Mers,  Tre- 
port,  Eu,  Sables -Olonne,  etc.  Several  cases  at  Orthez, 
Oloron  and  Creusot  were  attributed  to  Cette  oysters, 
and  at  Toulouse  to  Arcachon  oysters.  At  Autun, 
which  is  a  very  healthy  town,  forty  cases  and  one 
death  were  reported  in  October  and  November  1906; 
they  were  caused  by  the  consumption  of  barrels  of 
oysters  which  had  been  sent  from  Cette  or  the  pond 
at  Thaon. 


210    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  ingestion  of  raw  shellfish,  such  as  mussels, 
periwinkles  or  cocldes,  which  have  been  kept  in  or 
collected  from  polluted  water  in  the  neighbourhood 
of  sewers  or  in  harbours,  may  also  give  rise  to  typhoid 
fever. 

The  special  danger  of  oysters  is  to  be  explained  by 
their  mode  of  feeding.  They  feed  on  animalcules, 
living  or  dead  organic  particles,  such  as  diatomacese, 
bacteria,  etc.,  which  are  held  in  suspension  in  sea 
water.  For  this  purpose  their  buccal  apparatus  is 
surrounded  by  four  labial  palps  provided  with  vibra- 
tory cilia  which  draw  into  the  stomach  the  food  from 
the  water.  To  obtain  its  food  the  oyster  makes  a 
prolonged  aspiration,  which  enables  it  to  pass  through 
its  digestive  tube  a  very  large  quantity  of  water,  from 
which  it  removes  the  principles  in  suspension. 

If  some  living  oysters  are  put  in  an  aquarium  filled 
with  three  to  six  cubic  feet  of  turbid  water,  in  a  few 
days  the  water  will  become  clear.  The  oyster,  therefore, 
resembles  an  active  filter  which  retains  and  concen- 
trates the  impurities.  It  is  easy  to  understand  how 
the  oyster  becomes  loaded  with  numerous  harmful 
bacteria,  which  it  passes  on  to  man  when  it  has  fed 
on  highly  contaminated  water,  such  as  that  found 
in  sewers  or  harbours  into  which  fsecal  matter  is 
discharged. 

Bole  of  Drinking-water  and  other  Liquid  Foods. — 
Liquid  foods,  and  especially  water,  play  a  very  im- 
portant part  in  the  propagation  of  typhoid  fever.  Of 
all  ingesta,  drinking-water  is  the  most  responsible  for 
epidemics.  Ever  since  Brouardel's  warning  in  1877, 
countless  facts  have  testified  to  the  typhogenic  role 
of  this  factor,  "  Drinldng- water,"  said  Gueneau  de 
Mussy,  "is  an  important,  I  might  say  the  most  im- 
portant vehicle  of  the  typhoid  germ."  In  towns, 
large  communities,  and  the  army  in  peace  time,  drink- 
ing-water undoubtedly  claims  the  first  rank  as  the 
determining  cause  of  epidemics  of  typhoid  fever. 

Like  man  himself,  drinking-waters  have  their  own 
microbial  diseases,  which  are  often  due  to  a  continuous 


INDIRECT  CONTAGION  211 

invasion  of  the  micro-organism  in  question,  while  in 
other  cases  they  are  only  temporarily  contaminated 
by  the  dangerous  products  which  they  pass  on  to 
man.  There  are  thus  numerous  occasions  on  which 
he  may  be  infected,  such  as  the  swallowing  of  water, 
the  consumption  of  raw  vegetables  on  which  specifi- 
cally contaminated  water  has  been  poured,  and  various 
beverages,  such  as  milk,  cider  or  beer,  diluted  with 
impure  water;  and  lastly,  though  very  rarely,  by 
bathing  in  contaminated  water,  of  which  he  may 
absorb  a  certain  amount. 

In  this  respect  it  is  obvious  that  water  merely 
transmits  the  contamination  which  it  has  received. 
The  causes  for  its  pollution  are  very  numerous,  such 
as  human  excreta  coming  from  patients  or  carriers, 
urine,  laundry,  sewers,  etc.  Surface  water,  whether 
running  or  stagnant,  is  most  exposed  to  contamina- 
tion of  this  kind.  Deep  waters,  such  as  springs  or 
water  from  the  aquiferous  stratum,  may  get  patho- 
genic micro-organisms  from  the  soil  or  latrines  in 
their  passage  beneath  the  ground;  artesian  wells,  on 
the  contrary,  are  well  protected,  omng  to  their  great 
depth. 

Water  intended  for  drinking  does  not,  therefore, 
possess  any  special  bacterial  properties.  Its  purity 
depends  partly  on  the  geological  strata  through  which 
it  passes  and  the  receptacles  in  which  it  is  collected. 
In  inhabited  countries,  where  the  pollution  of  the  soil 
by  micro-organisms  extends  to  the  water,  the  amount 
of  germs  in  the  water  increases. 

Bacteriological  analysis  of  the  camp  subsoil  water 
was  made  in  1892,  in  the  camp  of  Hussein  Dey,  in 
which  epidemics  of  typhoid  fever  were  constantly 
occurring.  Before  the  arrival  of  the  troops  the  water 
was  very  pure,  and  contained  only  200  ordinary 
bacteria  per  c.c.  Six  days  later  the  analysis  showed 
770,  thirteen  days  later  420,  forty  days  afterwards 
6960,  sixty  days  afterwards  14,900,  and  three  months 
afterwards  38,000  (H.  Vincent).  This  is  an  illustra- 
tion of  the  progressive  infection  of  well  water  (phreatic 


212    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

water),  which  is  due  to  the  presence  of  men  on  the 
surface  of  the  soil,  the  duration  of  their  stay,  and  the 
faecal  contamination  which  results  therefrom. 

The  nature  of  the  soil,  whether  calcareous,  cal- 
careous and  fissured,  or  chalky,  obviously  influences 
its  degree  of  permeability  to  the  germs  deposited  on 
its  surface  and  washed  down  by  the  rain.  The  soil, 
even  at  a  depth  of  fifty  metres,  often  effects  but  an 
incomplete  purification  of  this  water.  From  this 
point  of  view  sandy  soil  is  the  best.  But  calcareous 
soil  with  large  joints  is  permeable  to  the  typhoid 
bacillus,  even  at  a  great  depth. 

A  fissured  soil  which  shows  holes,  cracks  and  crevices 
is  dangerous  in  this  respect,  for  it  gives  passage  to 
unwholesome  water  and  excrement  diluted  by  the 
rain  and  deposited  on  the  surface. 

The  holes  of  absorption  into  which  a  stick  can  be 
thrust  with  difficulty  serve  as  passages  for  the  surface 
waters  (Martel),  and  so  permit  of  the  contamination 
of  the  subsoil  water. 

It  is  a  well-established  fact  at  the  present  time 
that,  thanks  to  the  permeability  of  the  soil  and  the 
existence  of  holes  for  absorption,  fissures  and  crevices, 
as  well  as  subterranean  currents,  typhoid  faeces  may 
be  very  contagious,  in  spite  of  their  being  deposited 
at  a  great  distance  from  the  point  of  emergence  of  a 
spring.  All  the  springs  which  supply  Paris  with 
drinking-water  are  exposed  to  this  cause  of  infection. 
Faecal  pollution  of  one  of  the  reservoirs,  eight  to  ten 
kilometres  from  the  spring,  may  contaminate  it, 
especially  after  heavy  rain.  Rigorous  and  efficient 
protective  measures  have,  therefore,  been  taken. 

Waters  of  the  Vauclusian  type,  i.  e.  those  which, 
after  running  open  to  the  air  and  so  exposed  to  every 
possible  cause  of  pollution,  disappear  into  the  soil 
and  sometimes  emerge  again  in  a  remote  district,  are 
especially  dangerous  (Martel). 

The  inhabitants  of  Sauve,  in  the  department  of 
Gard,  thought  they  had  discovered  a  spring  when 
they  were  really  drinking  the  water  of  their  own  sewer. 


INDIRECT  CONTAGION  213 

In  the  Jura  Department,  says  Martel,  all  the  springs 
are  polluted  by  manure,  night-soil,  and  the  carcases 
of  animals.  A  well-known  example  of  a  dangerous 
outlet  is  that  of  the  Loue  spring,  which  is  merely  the 
water  of  the  Doubs,  which  disappears  at  Arcon.  In 
1901,  when  a  fire  destroyed  an  absinthe  factory  at 
Pontarlier,  the  spirit  flowed  into  the  Doubs,  with  the 
result  that  the  Loue  spring  acquired  a  taste  of 
absinthe. 

Very  numerous  examples  of  springs  with  a  reputa- 
tion for  purity  (Avre,  Vanne,  etc.)  have  been  shown 
to  communicate  ^vith  streams  which  flow  sometimes 
on  the  surface  of  the  soil  and  sometimes  below.  Thus 
the  Lunain  disappears  after  a  course  of  ten  to  fifteen 
kilometres. 

The  typhoid  infection  of  surface  arid  underground 
waters  is  brought  about  by  human  faeces  and  urine 
deposited  on  the  surface  of  the  ground  in  pits  near 
wells ;  it  is  also  caused  by  cultivation  of  the  soil  and 
the  dangerous  practice  of  manuring  it  with  dried 
human  dung.  The  rain  sweeps  the  ground,  follows 
its  declivities  or  infiltrates  the  soil,  carrying  pathogenic 
germs  with  it  into  the  subsoil  water. 

Sometimes  the  well  is  in  the  immediate  neighbour- 
hood of  a  privy  (P.  Brouardel) ;  certain  towns,  like 
Cherbourg,  still  show  examples  of  the  kind.  Some- 
times the  laundry  in  which  the  linen  of  typhoid  patients 
is  washed  is  close  to  the  spring  from  which  the  in- 
habitants get  their  water,  when  there  is  really  a 
subterranean  communication  between  the  spring  and 
the  laundry.  Water  in  ditches  situated  some  hundred 
metres  away  from  a  spring  may  be  seen  to  present 
oscillations  of  the  same  level,  showing  that  both  are 
connected  with  one  another.  Human  residues  and 
excreta  percolate  from  one  to  the  other. 

We  have  given  only  a  brief  sketch  of  the  commonest 
modes  of  adulteration  of  drinking-water.  They  easily 
explain  the  conveyance  of  the  typhoid  bacillus,  its 
absorption  sometimes  in  large  quantities  by  the 
inhabitants  of  a  town,  village,  barracks  or  school,  and 


214    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

the  occasionally  formidable  outbreaks  which  result 
therefrom. 

What  becomes  of  the  typhoid  bacillus  when  it  is 
discharged  into  water  ?  Does  it  multiply,  or  retain 
its  vitality  ? 

AU  bacteriological  investigations  have  shown  that 
the  typhoid  bacillus  hardly  ever  lives  more  than  four 
or  five  days ;  sometimes  it  is  impossible  to  find  it 
after  the  third  day. 

The  typhoid  bacillus,  therefore,  does  not  long  survive 
in  drinking-water . 

Moreover,  the  influence  of  diffuse  light,  and  especially 
of  the  direct  light  of  the  sun  (on  rivers,  ponds  and 
lakes),  has  an  energetic  sterilising  action.  In  clear 
water  the  bacillus  is  Idlled  in  four  to  six  hours  by  the 
solar  rays,  and  in  eight  to  nine  hours  in  turbid  water. 
The  actinic  rays  possess  the  most  active  power  (death 
in  two  and  a  half  to  three  hours),  while  the  heat  rays 
have  a  much  weaker  effect  (more  than  fourteen  hours) 
(H.  Vincent). 

But  so  long  as  it  persists  in  the  water  the  typhoid 
bacillus  retains  its  pathological  activity.  Besides,  it 
may  be  continuously  poured  into  drinking-water  by 
excreta,  urine,  laundry,  etc.,  and  so  keep  up  the 
dangerous  pollution  of  the  water. 

Numerous  epidemics  which  have  occurred  in  large 
towns,  villages,  barracks  and  cantonments  can  thus 
be  explained  by  the  consumption  of  polluted  water. 

The  idea,  therefore,  of  the  pathogenic  role  of  drinking- 
water  still  maintains  its  value  in  etiology. 

The  theory  of  germ  carriers  simply  completes  it, 
inasmuch  as  the  pollution  of  water  may  be  due  not 
only  to  the  excreta  and  urine  of  patients  suffering 
from  tj^phoid  fever,  but  also  to  carriers  as  well. 

In  war-time  contamination  of  drinking-water  depends 
upon  that  of  the  soil. 

In  his  hurry  to  relieve  himself  the  soldier  deposits 
his  excrement  without  any  precautions  in  ditches,  on 
the  side  of  the  road,  near  wells,  springs  or  water- 
courses, etc.,  and  washes  his  clothes  in  the  gutter. 


INDIRECT  CONTAGION  215 

Faecal  matter  accumulates  on  the  ground  in  enormous 
quantities,  especially  in  stationary  warfare,  like  the 
great  war  at  the  present  day. 

The  result  is  that  bacteriological  examination  rarely 
shows  a  water  of  wholesome  quality.  Most  waters 
are  intensely  infected  by  B.  coli  and  putrefactive 
microbes,  which  are  constant  associates  of  the  typhoid 
bacillus. 

Consequently,  in  war  time  one  should  a  priori  regard 
all  drinking-waters  with  suspicion  if  they  have  not 
been  thoroughly  sterilised. 

Paris  has  several  times  given  a  proof  of  the  very 
important  role  of  drinking-water  in  the  epidemiology 
of  typhoid  fever.  Brouardel,  Thoinot,  Chantemesse 
and  Widal,  Lancereaux  and  Mosny,  demonstrated  long 
ago  that  the  distribution  of  Seine  water  was  followed 
by  twice  to  six  times  as  many  cases  of  typhoid  fever 
in  the  hospitals.  In  1894  and  in  1900  the  Vanne 
water,  which  was  polluted  at  its  source,  was  the 
starting-point  of  serious  epidemics. 

Dr.  Hoel,  Director  of  the  Bureau  of  Hygiene  at 
Rheims,  has  drawn  attention  to  the  epidemic  of  1885, 
with  1500  cases  and  142  deaths,  which  occurred  for 
the  most  part  in  the  Ceres  quarter,  inhabited  by  the 
working  population,  which  drank  almost  exclusively 
well  water  into  which  cesspools  soaked. 

One  of  the  most  conclusive  examples  of  the  influence 
of  water  and  its  persistent  action  is  given  almost  every 
year  by  Marseilles. 

In  1907  this  town  had  more  than  3000  cases  of  typhoid 
fever  with  423  deaths.  In  1913  an  equally  severe 
epidemic  occurred.  Marseilles  receives  its  water  supply 
from  the  Durance,  whose  stream  is  exposed  to  the  air 
and  collects  on  its  course  human  excreta,  laundry 
water,  etc.  It  is  also  supplied  by  the  Rose  and 
Huveaume  water,  the  quality  of  which  is  equally 
doubtful. 

Cherbourg,  whose  civil  population  and  military 
and  naval  forces  have  frequently  suffered  from  typhoid 
fever,  owes  its  defective  sanitary  condition  to  the  use 


216    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

of  the  Divette  water.  From  1878  to  1887  its  naval 
and  military  forces  had  4162  cases,  with  400  deaths ! 
In  February,  1909,  a  new  epidemic  occurred,  with 
300  cases  and  60  deaths,  among  the  soldiers  and 
sailors.  The  river  Divette,  which  is  nothing  better 
than  a  sewer,  had  "been  polluted  on  January  6  by  the 
excreta  of  a  woman  suffering  from  typhoid  fever,  and 
continued  to  be  contaminated  throughout  her  illness. 
The  first  cases  of  typhoid  fever  occurred  on  January  25. 

The  epidemic  of  Saint-Brieuc  (June  1909),  in  which 
about  900  civilians  and  160  soldiers  were  attacked, 
was  due  to  the  washing  of  a  typhoid  patient's  clothes 
in  a  laundry,  the  water  of  which  ran  into  a  stream 
which  supplied  the  town. 

The  terrible  epidemic  of  Avignon  in  1911,  and  those 
of  Marseilles  in  1913,  and  of  Montauban  in  the  same 
year,  were  caused  by  the  impurity  of  the  drinking- 
water. 

In  the  garrisons  in  Algeria,  Tunis  and  Morocco, 
where  prior  to  specific  vaccination  typhoid  fever  used 
to  rage  with  an  appalling  violence,  bacteriological 
examinations  carried  out  in  the  laboratories  regularly 
showed  a  considerable  pollution  of  the  drinking-water. 
In  certain  towns,  indeed,  systematic  water  analysis, 
by  revealing  an  unusual  pollution,  enabled  one  to  fore- 
tell epidemics  which  actually  occurred  a  fortnight 
later.  At  Blida  in  1893  a  soldier,  who  wished  to  be 
sent  to  a  convalescent  hospital,  intentionally  swallowed 
a  large  quantity  of  condemned  water  (Oued  el  Kebir). 
He  contracted  typhoid  fever  from  which  he  died. 

The  study  of  the  epidemiological  facts  observed  in 
every  country,  including  England,  the  United  States, 
Italy,  etc.,  as  well  as  in  France,  has  fully  confirmed 
the  extreme  importance  of  the  bad  quality  of  drinking- 
water  in  the  etiology  of  typhoid  fever,  the  immunity 
which  those  enjoyed  who  did  not  drink  the  unwhole- 
some water,  and  the  occasionally  enormous  incidence 
of  the  disease  among  those  who  did. 

Beverages  derived  from  water  or  containing  water, 
such  as  ice,  Seltzer  water,  lemonade,  cider  and  milk. 


INDIRECT  CONTAGION  217 

may  give  rise  to  contagion.  Epidemic  cases  due  to 
the  consumption  of  impure  ice  were  reported  at 
Vannes ;  eight  officers  who  attended  a  banquet  in 
which  they  partook  of  ice  which  came  from  a  part  of 
a  river  where  several  sewers  opened,  contracted 
typhoid  fever.  Two  succumbed.  Two,  who  had 
drunk  beer,  escaped  (Major  Dorange,  1898). 

Milk  is  an  equally  dangerous  element  of  contagion 
when  it  is  drunk  unboiled.  Its  contamination  is  due 
to  its  having  been  taken  from  the  cow,  or  poured 
into  a  vessel  by  carriers  with  unclean  hands,  or  to  its 
having  been  collected  in  receptacles  washed  with  dirty 
water,  or  diluted  with  water  of  this  kind  which  contains 
the'  typhoid  bacillus.  In  England  Duncan  recorded 
in  1873  the  severe  epidemic  at  Crofeshall,  which  oc- 
curred among  500  families  who  had  consumed  milk 
infected  by  impure  water  taken  from  a  stream  into 
which  excreta  were  discharged.  The  families  who 
had  drunk  milk  from  another  source  escaped. 

Gueneau  de  Mussy  related  in  1881  the  history  of  the 
epidemic  in  Marylebone,  which  claimed  300  victims 
in  a  healthy  quarter  of  London.  The  milk  came  from 
a  farm  in  which  there  had  been  a  case  of  typhoid 
fever.  The  farm  well  received  the  leakings  of  a 
cesspool.  A  sanitary  inspector,  who  doubted  that 
this  was  the  cause  of  the  contagion,  drank  the  suspected 
water  and  contracted  typhoid  fever. 

A  very  severe  epidemic  due  to  contaminated  milk 
was  observed  in  1913  at  Jargeau  (Loiret).  It  gave 
rise  to  a  high  incidence  of  cases  in  certain  families 
(Grancher). 

Role  of  Flies. — The  part  played  by  flies  in  the 
propagation  of  certain  infectious  diseases  has  been 
proved  for  a  long  time.  Attracted  by  the  typhoid 
patients'  excreta,  vomit,  urine,  blood  and  pus,  or  by 
latrines  and  dimg-heaps,  flies  carry  off  the  typhoid 
bacillus  on  their  legs  and  proboscis  and  convey  it  else- 
where. The  typhoid  bacillus  lives  in  the  intestines 
of  flies  (CeUi,  Odium),  which  are  therefore  true  bacillus 
carriers.     They  become  filled  with  infectious  microbes, 


218    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

either  some  distance  away  or  in  neighbouring  houses, 
and  thus,  laden  with  elements  of  contagion,  they 
carry  them  into  kitchens  or  canteens  and  deposit  them 
on  the  food,  fruit,  pastry,  milk,  and  the  hands  and 
face.  They  are  contagious,  not  only  by  their  legs 
and  proboscis,  but  also,  and  perhaps  most  of  all, 
by  their  excreta,  for  they  defsecate  very  frequently. 

Their  danger  is  also  due  to  their  number,  which  may 
be  extraordinary,  especially  in  hot  seasons  or  climates. 
We  have  thus  undoubtedly  an  explanation,  in  part  at 
least,  of  the  predominance  of  typhoid  fever  during  the 
summer  and  autumn,  which  are  favourable  seasons 
for  the  multiplication  of  flies,  as  well  as  in  the  towns 
or  garrisons  in  the  south  of  France,  in  Algiers  and 
Tunis,  Morocco  and  all  the  countries  along  the  shores 
of  the  Mediterranean,  where  flies  swarm  in  such 
abundance.  This  also  explains  why  the  houses  of 
the  poor,  in  which  attention  to  cleanliness  and  hygiene 
is  too  often  neglected,  and  which  serve  as  a  home 
for  myriads  of  flies  during  the  summer,  are  frequent 
foci  of  typhoid  fever. 

Attention  has  been  called  to  contagion  by  flies,  to 
their  excessive  frequency  and  their  dangers  in  camps, 
especially  in  war-time,  by  army  medical  officers, 
during  the  expedition  to  Tunis,  the  Turco -Russian 
War  (Dobroslavine),  the  war  with  Cuba,  the  Transvaal 
War,  the  Russo-Japanese  War,  and  the  war  of  the 
Allies  with  the  Central  Empires. 

The  "  plague  of  flies,"  as  an  American  doctor, 
Sternberg,  called  it,  was  the  cause  of  the  great  fre- 
quency of  the  cases  of  typhoid  fever  seen  in  the  Spanish- 
American  War.  Being  inseparable  companions  of 
men  and  a,mmsils,  flies  act  as  a  powerful  and  formidable 
intermediary,  and  as  a  factor  of  contagion  of  the 
first  rank. 

The  English  army  doctor.  Odium,  published  in  1908 
the  account  of  a  very  severe  epidemic  which  occurred 
in  a  regiment  of  Highlanders  at  Nasirabad. 

The  usual  methods  having  failed,  a  systematic 
destruction  of   flies   was   carried  out.     The  epidemic 


INDIRECT  CONTAGION  219 

which  had  ceased  in  July  and  August,  returned  when 
the  flies  reappeared.  A  search  was  then  made  for  the 
breeding  places  of  the  flies,  especially  in  the  faecal 
trenches,  which  were  disinfected,  and  "  not  a  single 
case  more  of  typhoid  fever  was  observed." 

We  need  only  mention,  in  passing,  the  role  of  fleas 
and  lice,  which  has  sometimes  been  invoked,  but  never 
actually  proved.  The  relative  rarity  of  the  bacillus 
in  the  blood  of  the  typhoid  patient  prevents  us  from 
supposing  that  this  mode  of  active  infection  is  frequent 
or  even  possible. 


CHAPTER   XII 

CHARACTERS  AIsD  EVOLUTION  OF  EPIDEMICS  ACCORDING 
TO   THEIR   CAUSES 

In  the  previous  chapters  we  have  discussed  the 
respective  influence  of  the  various  factors  in  the  etiology 
of  typhoid  fever.  It  would  not  be  accurate  to  attribute 
an  equal  importance  to  each  of  these  modes  of  con- 
tagion. Some  there  are,  such  as  contagion  by  un- 
boiled milk,  oysters,  shellfish,  clothes,  and  raw  vege- 
tables, which,  though  fairly  olten  observed,  have 
not,  however,  the  same  frequency  as  others,  such  as 
the  influence  of  adulterated  drinking-water,  contagion 
due  to  flies,  direct  contagion  from  man  to  man  by 
patients  or  carriers,  etc. 

Though  its  importance  .  has  been  discredited  by 
some  hygienists,  the  role  of  drinking-water,  especially 
in  big  epidemics,  undoubtedly  still  claims  the  first 
place.  The  substitution  of  a  naturall}^  or  artificially 
pure  water  for  one  that  is  contaminated  has  been 
followed  by  an  unprecedented  reduction,  or  even  by 
the  almost  complete  disappearance  of  typhoid  fever 
in  a  large  number  of  towns.  It  is  especially  in  the 
soldier,  who  refiects  so  faithfully  the  sanitary  state 
of  a  town,  that,  thanks  to  the  active  and  persevering 
measures  demanded  and  obtained  by  army  medical 
officers,  a  considerable  improvement  in  sanitation  has 
been  obtained. 

Brussels,  London,  etc.,  like  Paris,  have  shown  a 
very  pronounced  drop  in  their  typhoid  incidence  and 
mortality,  following  the  installation  of  large  and 
expensive  works  for  supplying  pure  water. 

But  drinking-water  is  obviously  not  the  sole  factor. 

220 


CHARACTER  AND  EVOLUTION  OF  EPIDEMICS    221 

It  would  be  imprudent  to  suppose  that  a  pure  water 
supply  would  rid  the  civil  population  and  army  for 
ever  of  typhoid  fever. 

In  a  number  of  cases  bacteriological  and  chemical 
analysis  of  the  water  proves  its  good  quality,  whether 
it  is  that  the  cause  of  its  infection  is  transient  or  the 
culture  has  been  taken  too  late,  or  that  the  water 
really  is  pure. 

If  water  can  be  excluded,  in  the  presence  of  a  diffuse 
epidemic  without  any  appreciable  co-ordination  be- 
tween the  cases  in  time  or  space,  one  should  think  of 
one  of  the  other  causes  which  we  have  studied. 

During  the  hot  season,  and  especially  in  poor 
families,  flies  play  an  important  part. 

Investigation  should  be  made  as  to  contagion  by 
one  or  more  carriers  employed  in  an  occupation  con- 
nected with  the  preparation  of  food. 

In  such  cases  the  essential  element  of  the  contagion 
can  be  detected  by  the  inquiry  made  and  the  bacterio- 
logical examination. 

In  the  presence  of  an  epidemic  and  with  the  object 
of  cutting  it  short  as  quickly  as  possible,  it  is  necessary 
to  weigh  the  facts  impartially,  to  construct  a  map 
and  a  table  house  by  house  of  the  cases  observed,  of 
their  distribution,  succession  and  successive  onset. 
This  simple  analysis  by  means  of  the  map  may  furnish 
very  interesting  information.  Sterile  or  ill-founded 
hypotheses  should  be  avoided,  and  laboratory  help 
should  be  enlisted  to  detect  the  true  factors. 

It  is  important  to  know  that  when  an  epidemic 
has  taken  on  a  prolonged  course,  it  is  impossible  to 
attribute  it  to  a  single  factor  of  contagion.  All  causes 
and  methods  of  transmission  may  be  associated, 
such  as  direct  contact  with  the  patient,  consumption 
of  food  which  has  been  prepared  by  a  servant  who 
has  neglected  to  wash  his  hands  after  attending  a 
typhoid  patient,  contagion  by  a  carrier  who  has  also 
unclean  hands,  conveyance  of  the  germ  by  that 
dangerous  carrier  the  fly,  by  non-sterilised  linen,  a 
rectal   thermometer  or  bedpan  which  has  been  con- 


222    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

taminated  by  the  stools  or  urine  of  a  patient  and  not 
disinfected.  These  conditions  combine  with  one  an- 
other and  become  associated  with  the  initial  or  funda- 
mental cause  to  keep  up  the  supply  of  epidemic  cases 
and  prolong  their  effects. 

The  course  and  evolution  of  the  epidemics  themselves 
owe  their  special  character  to  the  cause  which  pro- 
voked them.  It  has  been  well  proved  that  epidemics 
due  to  water  are  widespread.  They  chiefly  affect 
persons  who  have  had  no  previous  attack  which  could 
have  immunised  them.  In  towns,  new  arrivals, 
including  soldiers,  travellers  and  servants,  are  specially 
affected. 

Furthermore,  epidemics  of  this  kind  due  to  drinking- 
water  have  almost  always  a  sudden  and  explosive  onset, 
affecting  a  large  number  of  individuals  all  at  once, 
and  in  a  short  space  of  time,  often  within  two  or  three 
weeks. 

Such  was  the  case  in  the  epidemic  of  Auxerre  (1884), 
so  well  studied  by  Dionis,  which  gave  rise  to  800  cases  ; 
in  the  Caterham  epidemic  (in  the  county  of  Surrey) 
in  1879,  which  affected  352  persons  simultaneously; 
in  the  epidemic  of  Chatillon-sur-Seine  (December 
1883)  described  by  Bouree ;  in  the  epidemics  of 
Cherbourg  and  Saint-Brieuc  in  1909;  in  the  celebrated 
epidemic  of  Avignon  in  1911,  which  gave  rise  to  more 
than  1000  cases  of  typhoid  fever,  etc.  These  epidemics 
may  last  several  months. 

It  is  also  observed  that  the  first  cases  begin  about 
fourteen  to  fifteen  days  after  the  use  of  impure  water, 
a  time  which  corresponds  to  the  minimum  duration 
of  the  incubation  of  typhoid  fever.  It  is  exactly  the 
same  in  the  cases  of  accidental  absorption  of  the 
typhoid  bacillus  in  laboratories.  But,  as  the  incuba- 
tion period  is  not  the  same  for  all,  a  series  of  later 
cases  may  occur,  twenty,  thirty  and  even  forty  days, 
even  after  laboratory  contagion. 

Epidemics  due  to  the  use  of  unboiled  milk  con- 
taminated by  water,  carriers,  or  flies  show  a  similarly 
sudden    and    simultaneous    character.     The    epidemic 


CHARACTER  AND  EVOLUTION  OF  EPIDEMICS    223 

is  at  first  limited  to  single  individuals,  to  the  customers 
of  the  infected  dairy,  or  to  families  which  make  use 
of  the  milk,  and  it  affects  those  exclusively  who  have 
drunk  it  unboiled. 

In  like  manner  the  consumption  of  oysters  or  shell- 
fish by  a  number  of  persons  may  have  a  similar  result. 

It  has  often  been  noticed,  and  Netter  has  quoted 
some  conclusive  proofs,  that  ingestion  of  water  or  food 
contaminated  by  the  typhoid  bacillus  causes  on  the 
same  or  following  day  an  attack  of  indigestion  accom- 
panied by  fever  and  diarrhoea. 

Typhoid  fever  appears  later  at  its  ordinary  date. 
It  seems  that  this  initial  diarrhoea,  which  might 
indicate  invasion  of  the  organism  by  the  typhoid 
bacillus,  is  more  probably  due  to  the  absorption  of 
other  bacteria  associated  with  the  specific  bacillus, 
such  as  proteus,  the  enterococcus  of  Thiercelin,  bacteria 
of  putrefaction,  etc. 

Epidemics  due  to  contagion  by  flies  show  a  sporadic 
character,  without  any  apparent  connection  between 
the  cases,  and  the  history,  as  well  as  the  search  for 
carriers  and  water  analysis,  are  unable  to  explain  them. 

Cases  of  typhoid  fever  due  to  contagion  by  carriers 
sometimes  appear  in  an  epidemic  form,  usually  of 
limited  extent,  but  more  frequently  in  a  sporadic  (or 
epidemic)  form.  These  cases  are  grouped  in  the  same 
house,  the  same  family  and  the  same  community. 
Their  onset  is  less  sudden  than  that  of  epidemics  due 
to  water,  and  their  extent  is  less  considerable. 

They  succeed  each  other  irregularly  and  are  abnor- 
mally prolonged,  in  every  season,  both  winter  and 
summer,  with  sometimes  a  long  interval  between  each 
and  without  any  obvious  connection. 

Their  frequency  depends,  indeed,  on  the  frequently 
intermittent  discharge  of  bacilli  in  the  excreta  and 
urine,  on  their  amount  which  is  always  less  than  in  the 
actual  course  of  typhoid  fever,  on  the  existence  of 
attacks  of  diarrhoea,  on  the  varying  degree  of  cleanliness 
of  the  germ  carrier,  on  his  occupation,  and  the  associa- 
tion of  special  circumstances  which  are  very  fortunately 


224    TYPHOID'FEVER  AND  PARATYPHOID  FEVERS 

not  always  combined,  so  that  the  chances  of  con- 
tamination are  restricted. 

It  is  needless  to  state  that  flies,  those  formidable 
agents  for  the  transmission  of  pathogenic  micro- 
organisms, and  especially  the  typhoid  bacillus,  make 
their  influence  felt  in  summer  and  autumn.  The 
accumulation  of  excreta  and  only  a  slight  fall  in  the 
temperature  may  prolong  their  existence,  not  only  in 
hot  countries,  but  also  in  temperate  climates. 

During  the  war  of  1914-1916,  flies  were  sometimes 
found  in  the  trenches  and  cantonments  during  part 
of  November. 


CHAPTER   XllI 

PROPHYLAXIS   OF   TYPHOID    FEVER 

Prophylaxis  of  Favouring  Causes 

The  description  of  the  ordinary  modes  of  contagion 
in  typhoid  fever  will  better  enable  us  to  deal  with 
the  various  prophylactic  measures  against  this  in- 
fectious disease. 

Considerable  importance  was  formerly  attached  to 
the  favouring  causes  of  this  disease.  Although  the 
bacillus  remains  the  only  responsible  agent  for  this 
process,  it  w^ill  be  well  to  consider  these  secondary 
factors  and  to  endeavour  in  practice  to  restrict  their 
action  as  far  as  possible. 

We  will  therefore  study  the  prophylaxis  of  the 
accessory  causes  which  favour  the  outbreak  of  typhoid 
fever.  Sjjecific  or  microbial  prophjdaxis  will  then  be 
discussed. 

Among  the  conditions  which  most  predispose  to  an 
attack  of  typhoid  fever,  age,  fatigue  or  overwork  and 
the  influence  of  heat  are  among  the  most  important. 

Age,  especially  adolescence  and  the  age  between 
eighteen  and  twenty-five  are  predisposing  factors 
which  we  cannot  guard  against.  Nevertheless,  they 
stimulate  us  to  multiply  during  this  period  all  the 
measures  for  removing  or  destroying  the  typhoid 
bacillus  (the  seed)  or  of  immunising  the  susceptible 
subject  (the  soil).  The  same  advice  is  applicable  to 
young  persons  of  both  sexes  who  are  devoted  to  sport 
and  indulge  in  it  to  excess,  which  frequently  leads 
to  loss  of  flesh  and  cardiac  or  renal  complications, 
and  to  those  who  are  preparing  for  examina.tions  and 

225 


226    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

competitions  without  sufficient  hygienic  precautions  or 
the  necessary  relaxation. 

In  the  army,  experience  has  shown,  contrary  to 
certain  apprehensions,  that  the  soldier  may  be  in- 
corporated at  the  age  of  eighteen  to  twenty  on  the 
condition  that  he  undergoes  a  progressive  training. 
It  is  therefore  necessary  to  confide  experienced 
medical  men  with  the  hygienic  supervision  of  young 
persons  of  both  sexes  who  are  devoted  to  sport,  as  well 
as  of  soldiers  who  have  recently  joined  the  army. 
Their  physical  education  should  be  conducted  with 
prudence,  otherwise  they  will  be  more  liable  to  in- 
fectious diseases  in  a  severe  form.  A  methodical  and 
progressive  training  should  be  insisted  upon. 

For  this  reason  the  societies  for  physical  education, 
military  education  and  gymnastics  should  be  warmly 
encouraged,  for  they  help  to  form  an  energetic  and 
supple  race,  which  is  better  able  to  resist  not  only 
fatigue,  but  also  the  morbid  conditions  which  are  so 
liable  to  attack  young  persons. 

Owing  to  the  influence  of  the  seasons  on  the  appear- 
ance of  certain  epidemic  diseases,  the  spring  may  be 
regarded  as  the  most  favourable  date  for  the  enrolment 
of  young  soldiers  in  peace  time.  In  the  Colonies  it  is 
best  to  mobilise  soldiers  in  the  winter. 

Expeditions  which  begin  during  the  hot  season, 
or  even  at  its  commencement,  have  been  paid  for  at 
the  price  of  violent  epidemics  of  typhoid  fever. 

It  should  be  added  that  the  prevention  of  the  disease 
by  an ti -typhoid  vaccination  diminishes  in  the  highest 
degree  the  influence  of  the  favouring  and  determining 
factors  which  we  have  studied,  just  as  the  preventive 
and  curative  use  of  quinine,  by  creating  a  sort  of  medi- 
cinal immunity,  has  considerably  reduced  attacks  of 
malaria  and  diminished  the  importance  of  its  occasional 
or  determining  factors. 

Side  by  side  with  physical  overwork,  demoralising 
causes  and  depressing  emotions  concur  in  predisposing 
to  typhoid  fever,  and  especially  to  grave  attacks. 
Every  practitioner  should  be  familiar  with  these  causes. 


PROPHYLAXIS  OF  FAVOURING  CAUSES     227 

The  general  hygiene  of  the  dwelling,  its  ventilation, 
the  exposal  of  the  rooms  to  the  light,  especially  of  the 
bedrooms  in  which  man  passes  at  least  a  third  of  his 
existence,  the  general  cleanliness  of  houses,  schools, 
factories,  etc.,  and  especially  that  of  kitchens,  dining- 
rooms,  latrines  and  court-j^ards,  and  their  proper 
ventilation,  all  constitute  a  collection  of  hygienic 
rules  which  are  applicable  not  only  to  the  prophylaxis 
of  typhoid  fever,  but  also  to  that  of  tuberculosis. 

The  same  remark  applies  to  barracks.  For  this 
reason  it  may  be  laid  down  as  a  principle  that  the  best 
position  for  barracks  is  in  the  heart  of  the  country. 

Life  in  camp  is  in  every  respect  more  wholesome 
than  in  towns  in  which  infections  of  every  kind  are 
often  accumulated.  The  mess-rooms,  latrines,  urinals 
and  punishment  cells  should  receive  special  attention 
from  the  regimental  medical  officers. 

The  child  should  be  instructed  in  individual  cleanli- 
ness, including  that  of  the  face,  mouth  and  hands. 
Regular  washing  of  the  hands,  especially  before  meals, 
should  be  a  constant  habit  and  a  sort  of  reflex  for  every 
one. 

This  early  education,  in  spite  of  its  importance,  is 
too  often  neglected,  especially  in  the  country.  It 
should  form  the  subject  of  a  few  lessons  in  elementary 
hygiene  by  the  school  teacher.  It  should  be  taught 
early  in  life,  so  that  it  should  not  be  forgotten  that 
cleanliness  is  one  of  the  manifestations  of  self-respect. 

In  this  exposition  of  the  prophylactic  measures 
applicable  against  accessory  or  favouring  causes  we 
can  obviously  give  only  general  indications.  A  de- 
tailed description  is  included  in  the  rules  relating  to 
microbial  prophylaxis,  properly  so-called.  For  this 
reason  it  will  be  sufficient  to  mention  the  favourable 
effects  of  a  careful  alimentary  hygiene,  and  to  recom- 
mend the  use  of  pure  water  and  wholesome  food 
protected  from  dust  and  contamination  of  every  kind. 

In  camps  and  cantonments,  in  peace  time,  and  in 
the  trenches,  huts,  and  temporary  or  permanent 
encampments    during    war,    one    must    combat    the 


228    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

formidable  danger  resulting  from  the  infection  of  the 
soil  by  human  or  animal  excreta,  urine,  kitchen  refuse, 
residues  of  all  kinds,  as  well  as  by  dung  heaps  and 
putrefying  matter  which  may  harbour  flies  and  their 
eggs.  Such  measures  constitute  indirect  prophylaxis 
of  the  utmost  importance. 

Therefore,  before  occupying  a  village  or  a  cantonment 
a  careful  inspection  should  be  made,  house  by  house, 
when  possible — which  the  conditions  of  a  war  of 
movement  do  not  always  readily  allow^ — ^a  note  should 
be  made  of  unwholesome  and  badly  ventilated  houses, 
with  their  accumulations  of  manure  which  serve  as 
huge  breeding-places  for  flies.  They  should  be  cleaned, 
disinfected,  washed  and  all  the  filth  cleared  out.  The 
best  means  of  profitably  disposing  of  dung-heaps  is 
to  scatter  them  as  soon  as  possible  over  the  fields  or 
the  soil  that  is  going  to  be  so\^ti,  at  a  sufficient  distance 
from  inhabited  dwellings. 

If  this  measure  cannot  be  carried  out,  they  should 
be  disinfected  or  even  burnt.  The  health  of  the  troops 
is  the  first  consideration.  The  manure-pit  and  pond 
into  which  the  rainwater  and  liquid  manure  drain 
must  be  filled  up  and  the  ground  disinfected. 

In  permanent  camps  the  ground  should  be  hardened, 
and  if  possible  paved,  wherever  the  soldier  is  living 
and  moving  about,  viz.  the  huts  and  tents,  and  at  all 
events  the  sides  of  the  road. 

All  depositing  of  manure  should  be  forbidden. 
Incinerators  should  be  built  for  destroying  kitchen 
refuse,  rubbish  and  filth,  which  may  putrefy  and 
attract  flies. 

Whenever  the  conditions  of  the  site  permit,  latrines 
with  drains  and  a  water  flush  should  be  installed. 

TJie  hygienic  arrangements  of  a  camp  should  as  far 
as  possible  resemble  those  of  a  town. 

In  the  absence  of  a  drainage  system  orders  should 
be  given  to  erect  latrines  with  pails  under  strict  super- 
vision, or  deep  trenches  which  must  be  carefully 
disinfected  twice  a  day  in  summer  and  once  daily  in 
winter. 


PROPHYLAXIS  OF  FAVOURING  CAUSES     229 

The  huts  and  tents  should  be  ventilated  during  the 
day.  The  approaches  to  them  must  be  strictly  clean. 
Night  latrines  render  real  service  not  only  in  barracks, 
but  also  in  cantonments  and  camps. 

Should  knowledge  of  the  ordinary  modes  of  propaga- 
tion of  typhoid  fever  be  the  exclusive  possession  of 
the  doctor  and  hygienist  ?  There  is  no  doubt  that  if 
spread  among  the  public  in  a  suitable  way  it  would 
have  a  good  effect  on  the  diminution  of  typhoid 
fever. 

Education  of  the  population  in  hygiene  can  only 
be  carried  out  with  the  active  assistance  of  public 
authorities  and  the  participation  of  the  medical 
profession.  It  should  form  an  integral  part  of  the 
instruction  given  to  children  (H.  Vincent),  and  should 
be  repeated  in  the  case  of  the  adult.  In  this  way 
every  one  will  be  properly  schooled  in  the  principles 
of  hygiene  and  become  the  conscious  collaborator  of 
the  medical  man. 

One  of  the  most  important  causes  of  the  spread  of 
epidemics  of  typhoid  fever  is  to  be  found  in  the  ignor- 
ance or  indifference  of  the  public.  For  this  reason 
summary  instruction,  imparted  in  informal  addresses 
given  by  a  medical  member  Of  the  Municipal  Board  of 
Health,  the  District  Commission  or  the  Council  of  the 
Department  would  serve  to  popularise  the  succinct 
principles  which  every  one  should  know,  relating  to 
the  parasitic  nature  of  contagious  diseases  and  their 
modes  of  propagation. 

Popular  instruction  imparted  at  school,  at  the  town 
hall,  in  the  workshop  or  at  home,  will  have  far-reaching 
effects  and  be  a  valuable  help  to  the  laws  and  regula- 
tions on  the  prophylaxis  of  infectious  diseases. 

An  immediate  inquiry  into  the  causes  which  started 
an  epidemic,  bacteriological  study  of  the  stools, 
examination  of  the  blood  by  culture,  or,  failing  that, 
by  the  serum  test,  will  be  of  considerable  help  in  the 
struggle  against  typhoid  fever. 

Bacteriological  study  alone  can  indicate  the  cause 
of  the  disease  and  thereby  enable  immediate  measures 


230    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

to  be  taken  for  the  isolation  of  the  patient,  disinfection 
of  the  stools,  linen,  latrines,  etc. 

It  will  become  possible  by  means  of  sanitary  stations 
and  laboratories  of  this  kind  to  restrict  the  frequent 
cases  of  contagion  from  man  to  man,  to  exercise 
supervision  over  drinking-water,  and  to  control  its 
bacteriological  quality. 

Except  in  the  army,  in  peace  as  well  as  in  war  time, 
in  which  all  beverages  are  analysed  and  forbidden  as 
soon  as  they  are  found  to  be  unwholesome,  bacterio- 
logical examination  of  water  is  practised  in  only  a 
few  towns. 

There  is  another  institution  which  is  absolutely 
necessary,  viz.  a  sanitary  register  of  parishes  and 
houses,  with  a  record  of  all  the  cases  of  infectious 
diseases,  and  especially  of  typhoid  fever.  The  cases 
of  illness  would  thus  draw  the  attention  of  the  Boards 
of  Health  and  facilitate  the  determination  of  the 
cause  of  epidemics. 


CHAPTER   XTV 

SPECIFIC   PROPHYLAXIS    OF   TYPHOID    FEVER 

The  progress  of  epidemiology  has  taught  us  the 
various  stages  through  which  the  bacillus  passes  to 
reach  man,  as  well  as  the  direct  causes  and  indirect 
factors  in  its  transmission. 

This  knowledge  having  been  acquired,  the  first 
measure  in  an  epidemic  consists  in  an  exact  bacterio- 
logical diagnosis  (typhoid  fever  or  paratyphoid),  and 
a  minute  and  as  complete  an  inquiry  as  possible  as  to 
the  first  case  and  those  which  followed  it,  both  at 
once  and  at  a  later  date ;  in  a  word,  as  to  the  collection 
of  conditions  which  may  foster  an  epidemic  or  endemic 
state. 

In  dealing  with  an  epidemic,  which,  after  all,  is  only 
a  collective  disease,  the  epidemiologist  should  behave 
like  a  doctor  with  his  patient.  He  should  discover  as 
soon  as  possible  the  exact  nature  of  the  affection,  by 
having  a  culture  taken  early  from  the  blood,  both 
of  patients  and  suspected  cases, ^  and  should  then 
endeavour  to  discover  the  one  or  more  causes  of  the 
disease  and  employ  the  appropriate  remedies. 

The  prophylaxis  of  tjrphoid  fever  should  have  in 
view  :  (1)  The  patient.  (2)  The  persons  about  him. 
(3)  Carriers.  (4)  All  inert  and  inanimate  agencies 
which  are  capable  of  carrying  the  typhoid  bacillus 
and  passing  it  on  to  man. 

Let  us  now  discuss  these  various  elements  of  con- 
tagion. 

^  It  appears  advisable  to  remind  the  reader  that  the  earlier  the 
blood-culture  is  taken  the  more  likely  it  is  to  be  positive.  The 
culture  should  be  taken  again,  and  a  larger  quantity  of  blood  should 
be  used  when  the  first  culture  is  negative. 

231 


232    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Every  typhoid  patient,  including  suspected  cases, 
should  be  isolated  as  early  and  completely  as  possible. 
This  isolation  should  precede  notification,  which  is 
compulsory.  It  is  unwise  to  await  the  confirmation 
of  the  diagnosis  by  the  clinical  symptoms  and  bacterio- 
logical examination  before  isolating  the  patient.  In 
the  case  where  isolation  has  not  proved  necessary, 
no  harm  results,  but  in  the  event  of  a  positive  diagnosis 
it  must  be  remembered  that  the  typhoid  bacillus  is 
present  in  large  numbers  in  the  stools,  not  only  at  the 
onset  of  typhoid  fever,  but  even  before  the  appearance 
of  the  first  symptoms. 

It  ^vill  be  necessary,  therefore,  to  exercise  super- 
vision over  the  patient's  household  who  may  already 
have  been  contaminated. 

All  delay  in  the  isolation  of  patients  and  suspected 
cases  may  expose  a  large  number  of  persons  to  con- 
tagion, especially  those  in  the  immediate  neighbour- 
hood of  the  patient.  Isolation  should  be  completely 
carried  out  in  the  army,  especially  in  war  time.  The 
patient  should  be  placed  under  observation  and 
removed  without  delay  with  a  provisional  diagnosis, 
if  the  febrile  symptoms  and  digestive  disturbances 
persist  or  get  worse.  It  is  right,  however,  to  mention 
that  in  war  time  it  is  very  common  to  observe  transient 
infections  which  clear  up  in  a  few  days  as  the  result  of 
rest,  purgatives  and  restricted  diet,  and  have  no  rela- 
tion with  typhoid  or  paratyphoid  fevers.  It  is  a 
peculiar  fact  which  is  worth  noting,  that  during  war 
time  infections  of  all  kinds  which  are  in  no  way  related 
to  one  another  are  apt  to  be  accompanied  by  gastro- 
intestinal disturbance. 

Blood -culture  and,  if  necessary,  cultures  of  the 
excreta  and  vomit,  will  help  in  the  diagnosis. 

In  hot  climates  and  in  the  East,  and  aU  the  countries 
along  the  shores  of  the  Mediterranean  where  malaria, 
papatacci  fever  (three -day  fever),  recurrent  fever  and 
Malta  fever  are  prevalent,  these  diseases  very  often 
assume  a  typhoid  disguise  which  may  mislead  the 
doctor.     Laboratory    examination    will    lead    to    the 


SPECIFIC  PROPHYLAXIS  233 

adoption  of  the  prophylactic  measures  required  by 
an  exact  diagnosis. 

No  rational  prophylaxis,  therefore,  can  be  carried 
out  either  in  the  army  or  in  the  civil  population  without 
aid  from  the  laboratory. 

As  soon  as  the  diagnosis  of  typhoid  fever  is  estab- 
lished, prophylactic  measures  should  be  rigorously 
employed.  After  isolation  of  the  patient  disinfection 
should  be  carried  out. 

This  applies  to  everything  that  has  been  contaminated 
by  fsecal  matter,  urine  and  expectoration  of  the  typhoid 
patient,  and  to  the  dead  body  as  well.  Disinfection 
of  the  walls,  the  air  and  the  room  in  which  the  patient 
has  been  under  treatment  is  of  less  importance.  But 
disinfection  of  the  floor, ^  which  is  frequently  con- 
taminated by  excreta,  and  also  of  the  linen,  spoons, 
glasses  and  bath  water  should  never  be  neglected. 

Disinfection  should  also  apply  to  persons  who  are 
looking  after  the  patient.  The  relations  and  nurses 
may  transmit  the  bacillus  to  those  about  them  by  means 
of  their  hands  or  their  clothes,  especially  if  they  are 
in  the  habit  of  preparing  the  meals.  They  may  also 
themselves  become  the  first  victims  of  their  negligence 
or  forgetfulness,  if  they  are  not  vaccinated.  Hands 
and  clothes  should,  therefore,  be  washed  or  disinfected 
as  often  as  is  necessary. 

Neglect  of  the  compulsory  notification  of  typhoid 
fever  ordered  by  the  law  of  February  15,  1902,  and 
the  decree  of  February  10,  1903,  has  too  frequently 
entailed  an  extension  of  the  disease  and  the  omission 
of  local  measures  of  disinfection. 

It  appears  certain  that  cases  are  not  notified  as  often 
as  they  should  be.  Medical  men  have  put  forward 
the  uselessness  of  this  notification,  because  it  is  not 
always  followed,  especially  in  the  country,  by  dis- 
infection. But  disinfection  does  not  constitute  the 
entire  prophylaxis  of  typhoid  fever,  and  it  is  for  the 
practitioner   to    have   the    measures    which   we    have 

^  Eau  de  Javelle,  a  hot  solution  of  caustic  soda  and  5  per  cent, 
solution  of  carbonate  of  soda  form  excellent  disinfectants  for  floors. 


234    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

already  described  carried  out  without  it  being  necessary 
to  have  recourse  to  official  intervention. 

The  rarity  of  notifications  has  also  been  attributed 
to  the  fear  of  hurting  local  trade  by  placing  a  ban  on 
a  business  house,  or  to  the  infected  districts  being  put 
out  of  bounds  for  men  on  leave  by  the  military 
authority.  Soldiers  too  frequently  bring  back  to 
barracks  the  infectious  diseases  which  they  have 
contracted  during  the  stay  in  their  village.  Such 
serious  consequences  demonstrate  the  absolute  neces- 
sity for  notification  of  typhoid  fever  and  other 
contagious  diseases. 

K  it  were  made  after  the  doctor  had  formally  ex- 
pressed his  opinion  on  the  case,  by  the  head  of  the 
family,  or  in  his  default  by  the  lodger,  as  is  the  rule 
on  the  declaration  of  births,  the  notification  would 
give  rise  to  fewer  objections. 

As  regards  the  persons  who  are  looking  after  the 
patient  or  are  in  his  immediate  vicinity,  arrangements 
should  be  made  to  vaccinate  them ;  they  should  be 
impressed  with  the  necessity  of  washing  their  hands 
carefully,  wearing  rubber  gloves,  changing  their 
overalls  or  smocks  when  they  are  contaminated ;  and 
of  never  eating  or  putting  their  hands  in  their  mouth 
in  the  patient's  room. 

Prophylaxis  with  regard  to  carriers. — No  regulations 
or  laws  have  been  laid  down  in  France  with  regard  to 
carriers.  The  Academy  of  Medicine,  nevertheless,  in 
1909  and  1910,  expressed  its  authoritative  opinion  on 
this  delicate  question. 

The  existence  of  carriers  undoubtedly  complicates 
the  prophylaxis  of  this  infectious  disease.  The  diffi- 
culty arises  from  the  fact  that  these  latent  carriers, 
who  are  moving  from  place  to  place  and  so  dissemi- 
nating unconsciously  the  typhoid  bacillus,  are  not  as 
a  rule  revealed  by  objectively  appreciable  signs.  It 
is  only  by  the  cultivation  of  their  excreta  that  the 
pathogenic  micro-organism  can  be  discovered,  and 
even  then  it  is  very  difficult  to  isolate. 

What    measures    should    be    adopted    against    this 


SPECIFIC  PROPHYLAXIS  235 

source  of  contagion  ?  Carriers  obviously  cannot  be 
compelled  to  submit  to  compulsory  isolation,  or  even 
to  legal  regulations  obliging  them  to  take  minute 
precautions  with  regard  to  their  excreta  and  urine. 
At  least,  nothing  has  been  done  hitherto  in  this  direc- 
tion. The  gravity  of  the  problem  cannot  be  hidden. 
It  is  complicated  by  the  fact  that  certain  carriers 
remain  so  all  their  lives. 

There  are,  indeed,  no  legal  remedies  for  carriers. 
It  is  only  in  cases  in  which  it  is  proved  that  they 
had  a  culpable  intention  of  doing  harm  that  the  law 
could  be  applied  to  them. 

Prophylaxis  consisting  entirely  in  investigating 
carriers  and  disinfecting  their  excreta  could  not  cut 
short  an  epidemic.  When  undertaken  locally  in 
Germany  in  1904,  with  an  abundance  of  precautions 
and  laboratory  examinations  which  would  render  it 
inapplicable  in  an  extensive  area,  this  method  seemed 
to  diminish  the  frequency  of  typhoid  fever  in  the 
region  under  supervision,  but  not  in  proportion  to  the 
effort  expended. 

AU  that  it  appears  possible  and  useful  to  do  consists 
in  informing  the  carriers  themselves  of  the  dangers  of 
their  faeces  and  urine,  and  of  the  manner  in  which  they 
can  make  themselves  inoffensive,  viz.  hy  careful  wash- 
ing of  their  hands  after  defcecation  and  micturition,  with 
prohibition  to  deposit  their  excreta  near  wells,  springs, 
or  in  gardens,  etc.,  sterilisation  of  body  linen  by 
boiling  water,  and  giving  up  every  occupation  con- 
nected with  the  preparation  of  food.  Carriers  should 
be  induced  to  take  these  precautions  in  their  o\vn 
interest. 

Have  there  not  been  instances  of  cooks  who  were 
found  to  be  disseminating  typhoid  fever,  and  were 
consequently  turned  out  of  all  their  situations  ?>  Some 
of  them,  however,  to  obtain  a  home  had  the  excreta 
of  a  healthy  person  analysed  in  place  of  their  own  ! 

With  convalescents  from  typhoid  fever  we  are 
better  able  to  cope.  The  recent  recollection  of  the 
danger  they  have  run,  and  the  advice  or  apprehensions 


236    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

of  their  friends,  who  have  been  enlightened  by  the 
doctor  as  to  the  contagious  character  of  germ  carriers, 
ensure  precautions  being  taken  for  the  time  being. 
The  difficulty  is  to  enforce  their  observance  for  a 
sufficiently  long  period. 

Persons  suffering  from  biliary  lithiasis,  chronic 
jaundice,  etc.,  should  be  told  that  they  are,  or  may  . 
be,  typhoid  or  paratyphoid  bacillus  carriers,  and  that 
the  most  serious  results  may  occur  if  they  follow  an 
employment  connected  with  the  preparation  of  food 
or  cooking. 

But  in  actual  practice  the  principle  of  individual 
liberty  will  doubtless  long  be  a  stumbling-block  to 
the  valuable  measures  which  society  claims  against 
carriers. 

We  must,  therefore,  try  to  find  a  method  by  which 
the  bacillus  carrier  can  be  effectually  freed  of  the 
bacilli  lodged  in  his  gall-bladder,  renal  pelvis  and 
bladder.  There  need  be  no  question  of  cholecystec- 
tomy, which  has  been  performed  without  causing  the 
bacillus  to  disappear. 

Specific  vaccination  of  the  carrier,  even  with  the 
bacillus  isolated  from  his  stools,  has  not  given  a  definite 
result.     It  is  the  same  with  the  use  of  lactic  ferments. 

One  is  therefore  led  to  conclude  that  the  best  pro- 
phylaxis for  the  contagion  due  to  carriers  consists  in 
preventive  vaccination  of  all  persons  living  in  contact 
with  them. 

Water  and  other  Beverages,  Food,  Flies,  etc. 

Drinking-water  is  of  great  importance  in  the  etiology 
of  epidemics  of  typhoid  fever.  In  the  rural  popula- 
tion, or  small  towns,  in  armies  on  manoeuvres  or  on 
active  service,  well-water  as  a  rule  is  responsible  for 
this  method  of  diffusing  the  germ.  Every  well  and 
every  spring  ought,  therefore,  to  be  surrounded  by  a 
zone  of  protection  against  pollution  by  dung-heaps, 
latrines,  etc.  But  the  difficulty  of  realising  such  a 
measure  in  private  property  is  very  great. 


SPECIFIC  PROPHYLAXIS  237 

The  civil  authorities,  however,  are  entitled  to  impose 
a  supervision  over  the  parish  wells,  and  to  demand  an 
adequate  zone  of  protection.  They  may  also  insist  on 
the  closing  of  the  wells  in  public  establishments,  hotels, 
restaurants,  inns,  cafes  and  bars,  which  have  been  found 
to  be  contaminated  on  baoteriological  examination. 

For  the  same  reason  the  military  authority  forbids 
the  troops  access  to  these  establishments.  But  in  war 
time,  in  which  half  measures  are  insufficient,  we  can 
but  approve  of  orders  which  formally  condemn  infected 
wells,  springs,  streams,  etc.,  and  which  command  a 
systematic  sterilisation  of  all  the  water  dnink  by  soldiers. 
Various  methods  described  in  textbooks  on  hygiene 
{v.  G.  H.  Lemoine,  Hygiene  Militaire.  Paris,  1911) 
show  how  this  may  be  carried  out.  The  simplest, 
most  practical  and  most  efficacious  method  is  treat- 
ment by  Eau  de  Javelle.  Alkaline  hypochlorites 
added  to  water  so  as  to  give  off  one  milligramme  of 
active  chlorine  per  litre  of  water  form  an  excellent 
sterlising  medium.  The  amount  of  chlorine  must 
always  be  first  estimated  by  a  chemist  or  dispenser, 
as  its  amount  varies  considerably  according  to  the 
origin  of  the  Eaii  de  Javelle. 

For  this  reason  calcium  hypochlorite  tablets  of 
varying  size  have  been  advocated  for  the  sterilisation 
of  the  water  to  be  purified  in  precise  amounts  of  one 
litre,  ten  litres,  etc.  (H.  Vincent  and  Gaillard).  Water 
purified  by  hypochlorites  should  not  have  a  percep- 
tible taste,  but  only  just  an  extremely  faint  odour. 
The  typhoid  bacillus  and  the  paratyphoid  bacilli  as 
well  are  killed  on  the  average  in  ten  minutes'  time. 

Numerous  towns  in  the  United  States  have  regu- 
larly employed  this  process  without  any  ill -effects. 
Free  chlorine  does  not  appear  to  attack  lead  or  earthen- 
ware pipes,  as  these  are  protected  by  the  calcareous 
coating  deposited  by  water.  At  Paris  treatment  by 
Eau  de  Javelle  is  employed  wherever  the  quality  of 
the  water  becomes  doubtful.  It  is  therefore  a  method 
of  very  great  and  practical  importance,  costing  little, 
inoffensive,  and  very  efficacious. 


238    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

We  have  said  that  other  beverages  than  water, 
e.  g.  milk,  can  convey  the  typhoid  bacillus.  All 
families  should  always  be  urged  to  boil  their  milk, 
the  danger  of  tuberculous  contagion  being  added  to 
that  of  typhoid  and  paratyphoid  contagion.  By 
having  the  milk  boiled  this  double  danger  is  easily 
remedied. 

Cider,  perry,  sour  wine  and  beer  may  also  give  rise 
to  typhoid  fever  if  they  are  diluted  with  contami- 
nated water,  or  are  contained  in  unclean  vessels  which 
have  been  washed  with  dirty  water,  or,  lastly,  if  they 
are  handled  by  carriers. 

During  the  war  of  1914-16  bacteriological  analysis 
of  certain  beers  from  the  north  of  France,  which  had 
been  drunk  by  our  soldiers,  showed  a  very  serious 
bacteriological  pollution  and  an  extraordinary  number 
of  micro-organisms. 

The  consumption  of  cider  and  of  sweet,  non-fermented 
wine  to  which  impure  water  has  been  added  is  also 
not  without  danger. 

The  only  method  of  prophylaxis  consists  in  the 
analysis  of  these  beverages  and  their  prohibition,  with 
penalties  in  case  of  disobedience  on  the  part  of  the 
dealers,  whoever  they  may  be,  and  whether  they  have 
received  a  licence  or  not,  but  especially  proprietors  of 
public-houses,  cafes,  inns  and  restaurants. 

Placards  and  notices  put  up  throughout  the  villages, 
cantonments,  etc.,  should  call  the  attention  of  the 
populace  and  the  soldiers  to  the  harm  and  dangers 
of  beverages  of  this  kind. 

The  prophylaxis  of  typhoid  fever  due  to  food  con- 
taminated by  faecal  matter  or  urine  depends  upon  the 
causes  which  provoke  this  contamination.  It  seems 
unnecessary  to  remind  the  reader  of  the  role  of  vege- 
tables, fruit,  radishes,  salad,  cress,  strawberries, 
cucumbers,  tomatoes,  etc.,  to  which  the  bacillus  may 
have  been  brought  directly  by  surface  disposal,  or 
indirectly  by  manure  in  epidemic  times,  or  in  dis- 
tricts in  which  typhoid  fever  is  prevalent ;  it  should 
be   hardly   necessary   to   order   abstention   from   raw 


SPECIFIC  PROPHYLAXIS  239 

vegetables,  etc.,  or  at  least  to  subject  them  to  careful 
and  prolonged  washing  in  cold  water.  It  should  also 
be  noted  that  flies  may  convey  the  germs  to  them 
later. 

The  important  question  of  surface  disposal  of  human 
manure — a  practice  employed  in  a  large  number  of 
agricultural  regions — is  closely  connected  with  infec- 
tion of  food,  as  well  as  of  the  soil  in  market  gardens, 
and  of  drinking-water,  when  the  ground  is  fissured 
and  provided  with  wells  or  cesspools. 

The  Academy  of  Medicine  energetically  condemned 
this  unwholesome  and  deplorable  custom  in  1900, 
The  Law  of  February  15,  1902  (Art.  1),  forbade  the 
surface  disposal  of  human  manure  within  the  protec- 
tive area  surrounding  wells ;  Art.  28  of  the  same 
law  enacted  penalties  against  any  one  who  let  excre- 
mentitious  matter  be  introduced  into  well-water. 
Municipal  authorities  are,  therefore,  armed  against 
surface  disposal.  But  this  repulsive  practice  is  pro- 
foundly anchored  in  country  habits,  and  habits  are 
often  stronger  than  laws.  In  fact,  no  legal  measure 
has  ever  been  taken  against  the  use  of  human  faecal 
matter  and  urine,  which  has  been  the  cause  of  so 
many  cases  of  typhoid  and  paratyphoid  fevers  and  of 
many  deaths.  It  is  at  least  necessary  for  existing 
legislation  to  be  completed,  reformed  and  strengthened, 
and  for  sxirface  disposal  to  be  forbidden  in  market 
gardens  in  which  vegetables  eaten  raw,  as  well  as 
strawberries,  are  grown,  and  also  at  a  distance  less 
than  a  hundred  metres  from  drinking -places,  springs, 
wells,  etc.,  used  for  drinking  purposes. 

Lastly,  prohibition  of  the  use  of  the  excreta  of 
patients  in  private  houses  or  hospitals  should  be 
equally  absolute. 

Epidemics  of  typhoid  fever  due  to  oysters  have 
formed  the  subject  of  numerous  reports.  The  super- 
vision and  regulation  of  oyster  parks,  and  the  pro- 
hibition to  lay  them  in  harbours,  near  the  shore,  or 
sewers,  or  to  keep  them  in  nets  plunged  in  these 
germ-saturated  waters,   have  several  times  been  de- 


240    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

manded  (Mosny),  but  without  effect.  For  this  reason 
Fabre-Domergue  has  suggested  the  placing  of  oysters 
in  pure  sea-water  for  a  few  days  to  enable  them  to 
get  rid  of  these  harmful  germs.  It  is  to  be  hoped 
that  such  wise  and  useful  measures  will  receive  the 
support  of  the  sanitary  authorities. 

As  we  have  said,  flies  form  important  agencies  for 
certain  germs,  such  as  the  typhoid  bacillus,  the  para- 
typhoid A  and  B  bacilli,  the  cholera  vibrio,  etc.  They 
settle  by  preference  on  food,  especially  fruit,  sweet- 
stuff,  cream  and  pastry.  Harm  may,  therefore,  ensue 
from  eating  this  food  in  epidemic  periods  when  there 
are  swarms  of  flies. 

Everything  that  can  prevent  flies  obtaining  a  fresh 
supply  of  germs  should  be  recommended,  including 
disinfection  and  cleanliness  of  the  patients,  their 
linen,  bedpans,  slop-pails,  sinks  and  latrines,  on  which 
cresyl  and  chloride  of  lime  powder  should  be  sprinkled. 
The  water-closet  system  represents  a  considerable 
progress  in  the  preventive  hygiene  of  typhoid  fever, 
by  limiting  the  contagion  by  flies  and  the  deposit  of 
germs  in  pails  or  the  subsoil. 

War  on  the  flies  themselves  and  their  reproductive 
activity  is  carried  on  by  disinfection  of  the  places 
where  they  lay  their  eggs  by  means  of  sulphate  of 
copper,  cresyl  and  chloride  of  lime,  by  clearing  out 
dung-heaps,  cleaning  manure-pits,  etc.  It  has  been 
suggested  that  the  dung-heap  should  be  placed  on 
hurdles  slightly  raised  from  the  ground;  the  pupae  of 
flies  which  infest  the  bottom  layer  of  the  dung-heap 
will  then  fall  upon  the  ground,  where  they  are  gobbled 
up  by  the  poultry  in  country  places. 

The  protection  of  the  windows  and  doors  of  kitchens 
and  dining-rooms  with  wire  blinds,  the  employment  of 
meat  safes  and  wire  covers  over  the  food,  constitute 
an  extremely  valuable  mechanical  protection.  This 
simple  and  useful  method  cannot  be  too  highly  recom- 
mended in  kitchens  and  canteens  in  association  with 
the  other  prophj'^lactic  measures  recommended  in  this 
work. 


SPECIFIC  PROPHYLAXIS  241 

To  destroy  the  flies  in  situ  pyrethrum  powder  dusted 
at  night  on  the  shelves,  furniture  and  tables  will  be  of 
great  service.  Fly-papers,  traps,  special  vessels,  bird- 
lime, etc.,  may  be  used  in  houses,  hospitals,  infirmaries 
and  ambulances. 

Good  results  can  be  obtained  by  leaving  at  night,  in 
the  kitchen  and  places  where  flies  accumulate,  plates 
and  saucers  containing  milk,  or,  better  still,  ordinary 
beer,  to  which  formol  (1  in  10)  has  been  added. 

These  measures  should  be  ofiQcially  ordered  in 
slaughter-houses,  pigsties,  porkbutchers'  shops,  but- 
chers' shops,  tinned  meat  factories,  and  generally  in  all 
establishments  and  factories  concerned  with  food. 


CHAPTER  XV 

PROPHYLAXIS  OF  TYPHOID  FEVER  IN  THE  ARMY 

The  causes  of  typhoid  fever  are  obviously  the  same 
in  the  army  and  in  the  civil  population.  The  pro- 
phylactic measures  already  described  find  their  appli- 
cation in  a  military  environment.  Owing,  however, 
to  its  excessive  susceptibility  and  almost  miiform 
manner  of  life,  food  and  age  of  its  component  parts, 
the  army  forms  a  special  environment,  in  which  pro- 
phylactic measures  are  perhaps  more  easily  and 
readily  carried  out. 

The  creation  of  military  bacteriological  laboratories 
for  the  analysis  of  drinking-water,  the  cultivation  of 
the  blood  and  stools,  the  investigation  of  suspected 
cases  and  carriers ;  the  institution  of  the  Chief  Council 
for  the  Supervision  of  Drinking-water  intended  for  the 
army,  which  has  rendered  considerable  service,  the 
stucUes  and  reports  to  which  the  onset  of  epidemics 
at  once  gives  rise  ^vith  hygienic  measures  taken  with- 
out delay,  all  testify  to  the  important  place  taken  by 
hygiene  in  our  army. 

The  law  of  March  28,  1914  (Leon  Labbe's  law), 
makes  anti-typhoid  vaccination  compulsorj^  Vacci- 
nation has  been  employed  in  certain  French  garrisons 
ever  since  the  year  1911,  first  of  all  in  East  Morocco, 
then  throughout  the  whole  of  Morocco,  Algiers  and 
Timis.  The  appearance  of  formidable  epidemics  in 
certain  garrisons,  viz.  at  Avignon  in  1912,  at  Mont- 
auban,  Issoudun  and  Marseilles  in  1913,  and  at  Tours 
in  1914,  determined  at  first  the  application  and  later 
the  generalisation  of  this  preventive  method. 

The  description  given  in  the  general  study  of  pro- 

242 


PROPHYLAXIS  IN   THE  ARMY  243 

phylaxis  will  allow  us  to  abridge  our  remarks  in  rela- 
tion to  prophylaxis  in  the  army,  both  in  war  and 
peace  time.  Only  a  few  supplementary  details  will  be 
given. 

As  soon  as  an  epidemic  appears  an  attempt  should 
be  made  to  recognise  and  combat  the  initial  cause, 
and  to  limit  the  extension  of  the  outbreak.  Conse- 
quently examination  of  the  blood  of  patients  and  sus- 
pected persons  should  be  made  as  soon  as  possible  by 
the  head  of  the  district  laboratory  in  time  of  peace, 
and  by  the  bacteriologist  of  the  army  corps  or  army 
laboratory  in  war  time. 

After  isolation  and  suitable  cultures  on  special 
media,  the  most  rigorous  measures  should  be  adopted 
as  soon  as  the  diagnosis  is  made.  The  patient  is 
isolated  in  a  special  ward ;  in  war  time  in  a  typhoid 
hospital.  His  stools,  linen,  bedpan  and  bath  are 
disinfected  in  the  way  described  below. 

Removal  to  hospital  must  take  place  early.  This 
should  apply  not  only  to  undoubted  cases,  but  also  to 
incomplete  forms,  cases  of  gastric  derangement  and 
diarrhoea  of  a  doubtful  character. 

The  patient  should  be  nursed  by  attendants  who 
have  been  vaccinated  against  typhoid  and  paratyphoid, 
and  are  provided  with  a  special  set  of  clothes,  which 
they  should  remove  on  leaving  the  ward.  The  atten- 
dants should  wash  their  hands  carefully  after  having 
bathed  the  patients,  or  changed  their  linen,  or  given 
them  the  bedpan  or  urinal.  The  use  of  rubber  gloves  is 
very  useful,  and  considerably  simplifies  the  precautions 
to  be  taken. 

Typhoid  cases  suffering  from  secondary  complica- 
tions, such  as  streptococcal  infection,  pneumonia, 
diphtheria,  etc.,  should  be  placed  in  isolation  rooms, 
as  such  cases  are  undoubtedly  contagious  to  other 
patients. 

Soiled  linen,  bedclothes,  handkerchiefs,  drawers,  etc., 
are  steeped  in  buckets  filled  with  warm  water  contain- 
ing Eaii  de  Javelle  in  the  proportion  of  20  per  1000. 
liinen  thus  treated  can  be  handled  without  danger, 


244    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

and  does  not  allow  any  contagious  particles  to  escape. 
Another  method  may  be  employed.  The  linen  should 
be  placed  in  a  disinfecting  bag  consisting  of  strong  and 
impermeable  cloth,  and  the  bags  are  then  taken  to 
the  laundry.  The  high  temperature  of  the  washing 
soon  gets  the  better  of  the  typhoid  bacillus. 

Disinfection  of  the  mattress  and  blankets  is  carried 
out  in  the  incubator  at  120°  C.  with  steam  to  facilitate 
the  penetration  of  heat. 

The  excreta  are  sterilised  before  being  thrown  away 
by  means  of  a  5  per  cent,  solution  of  cresyl  or  a  5  per 
cent,  solution  of  copper  sulphate.  The  urinals,  bed- 
pans and  slop-pails,  spittoons  and  their  contents  are 
also  sprinkled  with  these  antiseptic  solutions  and  then 
scalded;  water  at  100°  C.  instantly  kills  the  typhoid 
bacillus.  Its  bactericidal  properties  may  be  still  more 
increased  by  adding  5  per  cent,  solution  of  carbonate 
of  soda,  which  renders  it  alkaline  and  raises  its  boiling- 
point. 

To  disinfect  woollen  objects  or  clothes  they  should 
be  treated  with  formol  or  formacetone  vapour.  Mat- 
tresses, pillows  and  bolsters  require  the  same  treat- 
ment, but  they  must  be  undone  and  the  wool  or 
horsehair  exposed  in  thin  layers  to  the  action  of  these 
vapours. 

One  may  also  unpick  and  remove  the  covering  of 
the  mattress  and  plunge  it  in  Eau  de  Javelle  (20  in  1000) 
for  twenty-four  hours,  and  disinfect  the  wool  and 
horsehair  separately.  But  the  use  of  the  steam 
disinfectant  is  more  practical. 

Feather  pillows  and  eiderdowns  which  cannot  be 
sent  to  the  disinfector  should  have  their  covering 
disinfected  at  the  laundry  and  the  feathers  in  formol 
vapour. 

Spittoons  should  be  treated  with  5  per  cent,  solu- 
tion of  cresyl  or  a  2  per  cent,  solution  of  caustic  soda. 
.  Table  utensils,  such  as  spoons,  plates,  cups,  etc., 
are  collected  in  metal  baskets  of  iron  wire,  and  plunged 
for  several  minutes  in  boiling  water  rendered  alkaline 
by  a  5  per  cent,  solution  of  carbonate  of  soda. 


PROPHYLAXIS  IN   THE  ARMY  245 

Floors  and  walls  contaminated  by  excreta  6r  urine 
should  be  washed  with  a  hot  solution  of  5  per  cent,  of 
caustic  soda,  or  with  Eau  de  Javelle  of  the  same  strength. 

The  installation  of  a  drainage  system  in  hospitals 
or  wards  greatly  facilitates  the  emptying  of  the  bed- 
pans and  baths.  When  the  baths  have  to  be  emptied 
by  buckets  after  use  a  litre  of  Eau  de  Javelle  should 
be  poured  into  the  bath,  to  disinfect  at  once  the  bath 
and  its  contents.  The  bath  should  not  be  emptied 
until  some  hours  later. 

We  \\dll  now  consider  the  prophylactic  measures  to 
be  taken  in  barracks. 

The  cause  of  the  epidemic  having  been  determined, 
it  should  be  combated  without  delay.  It  must  not 
be  forgotten  that  persons  in  the  incubation  stage  of 
typhoid  fever  without  any  morbid  symptoms  dissemi- 
nate the  bacillus  with  their  excreta  in  latrines.  The 
water,  if  contaminated,  should  be  boiled  before  use. 
It  may  be  drunk  after  boiling,  or  as  weak  tea,  if  the 
barracks  have  no  sterilising  apparatus.  If  this  is  to 
be  had,  one  must  make  sure  that  it  is  working  properly, 
as  examination  has  sometimes  shown  that  it  may  be 
inadequate  or  imperfect.  The  rations  must  be  super- 
vised, and  raw  vegetables,  strawberries  and  unboiled 
water  prohibited. 

If  the  epidemic  originates  in  a  town,  the  cafes,  bars 
and  restaurants  must  be  put  out  of  bounds,  foj  the 
soldiers,  who  have  wholesome  water  to  drink  in 
barracks,  often  contract  the  disease  in  such  places. 

The  scale  of  work  should  be  reduced. 

After  having  sent  the  patients  and  suspected  cases 
to  hospital,  and  after  having  disinfected  their  sheets, 
bedclothes  and  body  linen,  the  stretchers  and  ambu- 
lance wagon  which  have  been  contaminated  by  them 
should  be  disinfected  if  necessary.  An  effort  should  be 
made  to  detect  any  abnormal  forms  of  infection  which 
may  give  rise  to  contagion. 

The  doors  and  windows  of  kitchens,  canteens  and 
eating-rooms  can  be  protected  to  advantage  by  a 
wire   blind,   to   prevent  the   entrance  of  flies.     Food 


246    TYPHOID  FEVER  AND  PARATYPHOID  FEV-ERS 

should  be  kept  in  a  safe  or  under  glass  covers  freed 
from  flies.  This  mechanical  protection  against  flies 
must  be  accompanied  by  the  various  precautions  de- 
scribed in  the  last  chapter  relating  to  the  destruction 
of  flies,  their  eggs  and  larvae. 

We  have  already  said  that  convalescents  may  have 
the  typhoid  bacillus  in  their  faeces  and  urine.  A 
search  for  carriers  is  possible  only  in  peace  time. 
Even  then  it  does  not  yield  all  the  results  expected. 
Systematic  disinfection  of  the  latrines  will  serve  to 
remove  this  cause  of  contagion  if  a  drainage  system 
does  not  exist.  One  must  on  principle  regard  all 
excreta  with  suspicion. 

Carriers  and,  as  an  additional  precaution,  even 
those  who  have  previously  suffered  from  typhoid 
fever,  should  be  forbidden  any  employment  in  con- 
nection with  the  kitchens,  canteens,  filters,  or  appa- 
ratus for  sterilising  water.  Cooks  should  be  ordered 
to  wash  their  hands  on  their  return  from  the  latrines 
or  the  urinal. 

During  manoeuvres  all  these  measures  are  applicable. 
The  same  applies  to  camps. 

Further,  inquiry  should  be  made  of  the  municipal 
authorities  about  the  sanitary  state  of  the  localities 
and  villages  in  which  the  men  will  be  quartered,  and 
about  any  prevalent  epidemics. 

Specimens  of  water  should  be  taken  for  rapid 
chemical  and  bacteriological  examination  (colimetry). 

Inns  and  public -houses  should  i^eceive  special 
attention. 

On  the  march  passage  through  infected  villages 
should  be  forbidden.  If  this  measure  cannot  be 
taken,  the  medical  officer  must  ask  for  absolute  pro- 
hibition being  given  to  the  troops  to  stop  at  all  in 
such  places  to  buy  any  milk  or  drink  (cider,  etc.),  or 
take  any  water. 

In  camps  in  which  very  severe  epidemics  of  typhoid 
fever  have  often  been  observed  very  strict  measures 
should  be  adopted  to  prevent  the  invasion  and  spread 
of  the  bacillus. 


PROPHYLAXIS  IN  THE  ARMY  247 

The  camp  should  not  be  erected  over  a  previously 
infected  site  or  over  old  faecal  trenches.  These  must 
be  looked  for  and  avoided. 

The  kitchens  and  canteens  should  he  situated  far  from 
the  latrines,  fcecal  trenches,  urinals  and  stables,  owing 
to  the  danger  of  flies. 

Whenever  it  is  possible,  especially  in  permanent 
camps,  a  drainage  system  should  be  provided. 

The  faecal  trenches  should  be  carefully  supervised, 
and  disinfected  with  chloride  of  lime  powder  once  a 
day  in  winter  and  twice  daily  in  summer  on  account 
of  the  flies.  Their  approaches  should  also  be  powdered 
with  antiseptics. 

The  water  should  be  analysed  and,  if  doubtful, 
sterilised. 

Raw  vegetables  and  unboiled  milk  may  be  the 
source  of  grave  dangers,  and  should  be  forbidden  as 
soon  as  suspected  or  definite  cases  of  typhoid  fever 
appear. 

The  occurrence  of  the  first  case  requires  immediate 
and  energetic  precautions,  viz.  dispatch  of  the  patient 
to  hospital,  removal  of  the  tent,  incineration  on  the 
actual  spot  of  the  straw  on  which  he  lay,  disinfection 
of  linen,  contaminated  objects,  etc. 

Removal  to  hospital,  into  an  observation  ward  for 
doubtful  cases,  containing  patients  with  gastric  de- 
rangement, etc.,  has  a  real  practical  importance. 
Their  linen  should  be  sent  to  be  disinfected  as  if  they 
were  really  suffering  from  typhoid  fever,  and  the 
straw  on  which  they  lay  should  be  burnt. 

As  many  of  these  cases  are  due  to  infection  by  para- 
typhoid bacilli,  Thiercelin's  enterococcus,  etc.,  these 
precautionary  measures  will  always  be  advantageous. 

Soldiers  must  be  forbidden,  on  pain  of  severe 
penalties,  to  pollute  with  liquid  human  fseces  the 
camp  soil,  the  approaches  to  the  tents  and  huts,  and 
the  surroundings  of  wells  or  springs. 

Night  latrines  with  pails  should  be  installed  as  in 
barracks,  being  closed  by  day  and  carefully  disinfected. 
They  should  be  lighted  up  at  night. 


248    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Protection  of  food  against  flies  and  the  destruction 
of  the  flies  themselves  must  receive  special  attention. 

Kitchen  refuse,  scraps  of  food  and  rubbish  should 
be  burnt  in  special  destructors,  easy  to  construct  and 
provided  with  a  powerful  draught.  They  should  be 
situated  at  one  of  the  extremities  of  the  camp,  so 
that  the  prevailing  wind  does  not  drive  back  the 
smoke  upon  the  camp. 

The  specific  prophylaxis  of  typhoid  fever  in  war 
time  is  obviously  based  on  the  same  principles  as 
those  set  forth  above. 

The  establishment  of  army  and  arm/y  corps  bac- 
teriological laboratories,  as  well  as  mobile  sanitary 
sections  with  portable  apparatus,  forms  part  of  the 
prophylactic  measures  required  by  the  fight  against 
typhoid  fever  in  war  time.  They  inform  the  Health 
Service  as  to  the  quality  of  the  drinking-water,  the 
exact  nature  of  the  diseases,  as  well  as  the  doubtful 
cases,  germ  carriers,  etc.  They  make  blood-cultures, 
diagnoses  of  the  first  cases,  which  are  always  so 
important,  and  bacteriological  analyses  of  drinking- 
water. 

As  the  causes  of  epidemics  are  multiple,  the  pro- 
phylaxis of  typhoid  fever  always  presents  the  greatest 
difficulties  in  armies  on  active  service.  The  specific 
preventive  method,  vaccination,  alone  enables  us  to 
combat  them  all  successfully  at  once.  We  shall  deal 
with  this  subject  later. 

War  conditions  do  not  always  permit  of  every 
prophylactic  measure  being  rigorously  carried  out. 
Medical  officers  will  therefore  need  much  energy, 
persistence,  self-confidence  and  initiative  to  obtain 
results.  But  these  results  are  always  forthcoming 
when  prophylaxis  is  applied  conscientiously,  without 
forgetting  or  failing  to  carry  out  even  the  minutest 
detail.  Any  neglect,  omission  or  half -measures  result 
in  prolongation  of  epidemics  and  the  death  of  a  large 
number  of  soldiers.  It  is  the  duty  of  the  medical 
officers  whose  mission  it  is  to  give  the  orders,  as  for 
those  who  have  to  carry  them  out,  to  neglect  nothing 


PROPHYLAXIS  IN   THE  ARMY  249 

in  the  war  against  the  germ  of  typhoid  fever.  It  is 
a  fact  that  soldiers  in  general  are  opposed  to  hygienic 
measures  of  any  kind.  These  must,  therefore,  be 
made  compulsory,  and  it  must  be  realised  that  the 
role  of  the  medical  officer  and  hygienist,  which  is  to 
keep  a  large  body  of  men  in  a  sound  condition,  is  one 
of  national  defence.  The  commanding  officer  should 
be  associated  with  these  measures,  and  his  assistance 
obtained  by  convincing  him  of  their  value. 

All  the  prophylactic  measures,  therefore,  which  we 
have  recommended  find  their  application  in  war  time. 
The  bacteriological  control  of  drinking-water,  its 
purification  by  boiling  or  treatment  with  Eau  de 
Javelle,  should  be  carefully  carried  out.  The  chief 
medical  officers  and  the  divisional  medical  officer 
should  exercise  a  constant  supervision,  so  that  the 
men  should  not  drink  any  other  water  than  that  ivhich 
has  been  purified.  Every  one  knows  that  the  soldier 
has  a  natural  tendency  to  drink  any  water  he  finds, 
whether  dangerous  or  not.  It  is  not,  therefore, 
enough  to  show  him  the  grave  risks  he  is  running. 
He  must  be  prevented  from  drinking  such  water  by 
police  measures,  such  as  closing  or  guarding  a  suspected 
well  or  unwholesome  spring. 

The  fight  against  flies  which  carry  harmful  germs 
forms  part  of  the  necessary  prophylactic  measures, 
and  should  be  accompanied  by  the  destruction  by 
incineration  of  faeces,  rubbish,  kitchen  refuse  and 
putrescible  matter,  or  by  their  disinfection  by  chloride 
of  lime,  cresyl,  or  5  per  cent,  solution  of  sulphate  of 
copper.  The  methods  of  protection  against  flies  have 
already  been  described. 

The  faecal  matter  of  persons  in  the  incubation  stage 
and  during  the  actual  disease,  and  of  convalescents 
and  carriers  as  well,  remains  the  essentially  dangerous 
element  of  direct  or  indirect  contagion. 

It  is  to  be  found  in  large  quantities  in  places  occupied 
by  troops.  There  can  be  no  question  of  making  a 
search  for  typhoid  or  paratyphoid  carriers  in  a  very 
large  body  of  men.     The  German  method,  which  is  of 


250    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

difficult  application  in  peace  time  with  the  technique 
at  present  available,  would  be  out  of  the  question 
in  war  time.  It  is  simpler  and  more  practical,  as  well 
as  more  rational,  to  consider  on  principle  all  human 
excreta  as  dangerous  and  to  treat  them  as  such. 

Dung-heaps  keep  up  the  supply  of  flies,  which 
multiply  in  an  extraordinary  degree  in  war  time. 
These  dung-heaps  often  form  enormous  accumulations, 
and  it  is  not  without  difficulty  that  the  sanitary 
service  of  the  army  can  rid  the  cantonments  of  them. 
If  one  cannot  force  the  inhabitants  to  do  away  with 
dung-heaps,  it  is  best  to  have  them  taken  away  by 
fatigue  parties,  and  spread  in  thin  layers  over  the 
cultivated  fields  in  the  neighbourhood  at  a  distance 
from  the  houses. 

Men  with  suspicious  symptoms  should  be  urged  to 
report  themselves  to  the  medical  officer  without  delay. 
It  has  too  often  been  found  that  soldiers  suffering  from 
typhoid  fever  do  not  report  sick  until  they  have 
reached  the  last  extremity  and  their  strength  is  giving 
way.  Some  have  been  able  to  go  to  the  trenches 
although  they  had  undoubted  symptoms  of  the  dis- 
ease. This  reluctance  on  the  part  of  the  combatant 
soldier  has  very  grave  consequences,  both  for  himself 
because  it  is  the  cause  of  the  high  case  mortality 
observed  in  the  present  war,  and  for  others  because 
it  results  in  specific  contamination  of  the  ground, 
trenches,  drinking-water,  etc.,  with  excreta  rich  in 
bacilli. 

The  problem  of  contagion  in  the  trenches  undoubt- 
edly raises  considerable  practical  difficulties.  The 
makeshift  latrines  erected  in  well -sheltered  offshoots 
from  the  trenches  are  not  always  used  by  the  soldier, 
either  because  he  is  in  a  hurry  to  relieve  himself  or 
because  he  has  to  change  his  position,  which  some- 
times exposes  him  to  the  fire  of  the  enemy.  The 
deposit  of  faecal  matter  in  the  trenches  where  the 
soldier  fights,  rests,  takes  his  food,  and,  generally 
speaking,  lives  for  several  days,  results  in  contami- 
nating his  clothes,  boots  and  hands.     This  contamina- 


PROPHYLAXIS  IN   THE  ARMY  251 

tion  is  obviously  followed  by  that  of  the  alimentary 
canal.  When  mixed  with  mud  the  faecal  matter 
escapes  notice,  and  is  therefore  all  the  more  dangerous. 

The  occupation  of  the  enemy's  trenches  after  a 
fight  offers  the  same  grave  dangers  of  contamination. 
This  is  the  explanation  of  the  propagation  of  typhoid 
and  paratyphoid  fevers,  dysentery,  enterococcus  infec- 
tions and  trench  diarrhoea  during  the  present  war. 

For  this  reason  regimental  medical  officers  should 
endeavour  to  prevent,  whenever  possible,  any  faecal 
contamination  of  the  soil  of  the  trenches.  The  offenders 
and  the  companies  in  which  these  cases  of  uncleanli- 
ness  are  observed  should  be  regarded  as  responsible, 
and  ordered  to  disinfect  the  areas  contaminated  by 
the  excreta  with  chloride  of  lime.  The  disinfected 
matter  should  then  be  buried  in  deep  holes  far  from 
the  water  supply. 

Except  under  special  circumstances,  patients  and 
doubtful  cases  should  make  only  a  very  brief  stay  in 
the  ambulances  situated  near  the  lines.  They  should 
be  taken  to  special  infectious  hospitals,  where  there 
will  be  facilities  for  isolating  them,  for  making  bac- 
teriological diagnosis  by  blood -culture,  repeated  if 
necessary,  and  for  nursing  them. 

The  removal  of  typhoid  patients  should  be  carried 
out  under  supervision.  Sterilisation  of  the  patients' 
faeces  and  urine  during  the  journey  should  be  ordered. 
Arrangements  should  be  made  to  avoid  contamination 
of  the  transport  vehicles,  automobiles,  wagons,  boats, 
canals,  etc.  There  may  be  some  risk  in  transporting 
to  a  distance  typhoid  patients  who  have  reached  an 
advanced  stage  of  their  disease,  in  whom  intestinal 
perforation  or  accidents  due  to  myocarditis  are  to  be 
apprehended. 

The  official  report  should  indicate  without  delay 
not  only  the  definite  and  exact  diagnosis,  but  also 
the  possibility  of  suspected  cases,  so  that  precautions 
should  be  taken  early  to  cut  short  the  epidemic. 

All  the  special  precautions  and  measures  we  dis- 
cussed in  detail  when  we  dealt  with  the  prophylaxis  of 


252    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

typhoid  fever  in  the  civil  population,  as  well  as  in  bar- 
racks, camps  and  cantonments  and  during  manoeuvres. 
There  is,  therefore,  no  need  to  mention  these  again. 
In  addition  to  supervision  of  the  drinking-water, 
protection  against  flies,  disinfection  of  faecal  matter, 
urine,  rubbish,  etc.,  we  may  remind  our  readers  that 
every  man  Avho  has  had  an  attack  of  typhoid  or  para- 
typhoid, especially  recently,  should  be  forbidden  to  act 
as  cook,  as  he  may  be  dangerous  in  this  employment. 

It  would  be  well  if  every  soldier's  book  contained 
as  an  appendix  a  chapter  on  hygiene,  informing  him 
in  a  simple  and  summary  manner  how  infectious 
diseases  are  contracted,  especially  typhoid  fever,  the 
precautions  to  be  taken  to  avoid  them,^  the  dangers 
of  alcoholism,  etc. 

Specific  prophylaxis  does  not  apply  to  the  infecting 
germ  only,  or  merely  aim  at  its  destruction.  It  should 
also  endeavour  to  protect  from  infection  by  active 
immunisation  all  the  persons  exposed  to  contract  the 
disease.  This  active  immunisation  is  obtained  by 
inoculation  of  the  dead  virus.  Such  is  the  principle 
of  preventive  vaccination,  which  has  given  remarkable 
results  whenever  it  has  been  properly  carried  out. 
We  shall  deal  with  it  after  our  epidemiological  study 
of  paratyphoid  fevers. 

1  H.  Vincent,  Congres  International  de  Medecine.  Section  de 
Pathologie  Militaire.     Paris,  1900. 


CHAPTER    XVI 

ETIOLOGY   AND    PROPHYLAXIS    OF   PARATYPHOID 

FEVERS 

Typhoid  fever  on  the  one  hand,  and  paratyphoid 
fevers  on  the  other,  constitute  entirely  independent 
diseases.  In  spite  of  the  close  similarity  of  their 
symptoms,  and  although  the  bacilli  causing  them  belong 
to  the  same  family  of  micro-organisms,  these  affections 
do  not  confer  upon  each  other  reciprocal  immunity. 
It  may  happen  that  the  same  person  may  contract 
in  succession,  and  at  a  few  months'  interval,  typhoid 
fever  and  then  a  paratyphoid  fever.  Cases  have 
been  knoT\Ti  in  which  the  three  diseases,  typhoid  fever, 
paratyphoid  fever  A  and  paratyphoid  fever  B,  have 
occurred  A\dthin  a  little  more  than  a  year  in  the  same 
person,  who  had  been  successively  exposed  to  the 
contagia  of  these  three  diseases. 

Such  cases,  undoubtedly,  are  not  frequent.  But 
one  must  consider  the  possibility  of  their  occurrence 
in  interpreting  repeated  attacks  of  typhoid  fever  in 
the  same  individual.  Such  cases  are  possible,  but, 
in  the  absence  of  a  blood-culture,  an  exact  diagnosis 
cannot  be  made. 

The  nosological  independence  of  paratyphoid  fevers 
one  from  the  other  and  from  typhoid  fever  is  also 
illustrated  in  epidemiology.  Before  the  important 
discovery  of  paratyphoid  baciUi  by  Achard  and 
Bensaude  in  1896,  it  is  certain  that  the  infections  due 
to  these  pathogenic  micro-organisms  were  usuall}^ 
confounded  with  typhoid  fever,  and  sometimes  with 
certain  forms  of  cholera  nostras.  Bacteriological 
examinations,  by  indicating  the  exact  nature  of  the 
infections  and  attributing  them  to  their  true  pathogenic 

253 


254    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

agent,  have  helped  to  prove  the  existence  of  autonomous 
epidemics  of  paratyphoid  fever.  On  other  occasions 
cases  of  typhoid  fever  were  found  in  association  with 
paratyphoid  fever.  Before  the  war  of  1914  paratyphoid 
fevers  were  seen  in  the  form  of  small  epidemics,  usually 
of  the  B  type.  In  the  army,  where,  following  the 
introduction  of  antityphoid  vaccination,  blood-cultures 
were  taken  from  patients  suffering  from  doubtful 
affections,  this  disease  was  found  to  be  very  frequent 
in  soldiers,  whether  vaccinated  or  not.  Some  ex- 
tremely violent  epidemics  which  occurred  at  Marseilles, 
Avignon,  Tours,  etc.,  were  exclusively  due  to  the 
typhoid  bacillus,  and  the  local  laboratories  reported 
only  a  few  isolated  cases  of  paratyphoid  fever  B. 
Paratyphoid  A  was  less  frequent. 

Sacquepee  and  Chevrel  have  noted  that  the  town 
of  Rennes  was  fairly  often  infected  by  paratyphoid 
fever.  The  disease  is  particularly  frequent  in  parts 
of  Paris  and  in  the  west  of  France  (Brittany).  It  has 
been  seen  almost  everywhere.  In  Europe,  Germany 
forms  the  most  important  seat  of  paratyphoid  A  and 
B.  This  frequency  of  the  disease,  which  may  be  so 
high  as  to  constitute  10  per  cent,  of  the  diseases  of  a 
typhoid  form,  is  doubtless  connected  with  the  nature 
of  the  food  usually  eaten  in  that  country. 

The  existence  of  paratyphoid  fevers  has  been  noted 
in  Italy,  England,  Holland,  Roumania  and  other 
European  centres ;  in  Africa  (Algeria,  Tunis,  Morocco, 
Libya,  Egypt,  Senegal,  South  Africa,  etc.);  in  the 
United  States,  Brazil,  Philippine  Islands,  Japan 
(Shibayama),  Indo -China,  etc.  The  disease  is,  therefore, 
ubiquitous. 

War,  by  reason  of  the  exceptional  conditions  which 
it  creates,  favours  in  the  highest  degree  the  appearance 
of  gastro -intestinal  disease,  such  as  bacillary  and 
amoebic  dysentery,  ordinary  diarrhoea,  and  the  so- 
called  trench  diarrhoea,  as  well  as  typhoid  fever. 
The  f requeue}'  of  paratyphoid  fevers  A  and  B  has  thus 
been  demonstrated,  especially  in  August  1915,  when 
they  were  predominant  in  the  armies. 


ETIOLOGY  OF  PARATYPHOID  FEVERS      255 

Vaccination  against  typhoid  fever  in  no  way  predis- 
poses to  paratyphoid  fevers  A  or  B.  Before  the  war 
with  Germany  these  were  extremely  rare  in  the  French 
Metropole  army,  although  this  contained  more  than 
200,000  vaccinated  persons.  In  the  English  army 
in  India,  which  was  almost  entirely  vaccinated  against 
typhoid  fever,  there  were  only  a  few  cases  of  para- 
typhoid fevers.  It  was  the  same  in  the  United  States 
army. 

The  war  with  Grermany  gave  rise  to  a  fairly  large 
number  of  cases  of  paratyphoid  fever  through  contagion 
(as  well  as  of  bacillary  or  amoebic  dysentery),  which 
were  controlled  by  specific  vaccination. 

The  influence  of  races  and  their  predisposition  to 
paratyphoid  infection  have  not  been  settled.  Cases 
appear  to  be  more  frequent  in  hot  countries,  but  war, 
by  greatly  increasing  the  opportunities  for  contagion, 
is  undoubtedly  the  most  important  of  all  favouring 
causes.  Chevrel,  on  the  ground  that  in  a  given  country 
certain  areas  are  specially  affected,  maintains  that 
there  are  undetermined  "  regional  influences."  It  is 
more  probable  that  these  influences  are  connected 
with  defects  in  the  hygiene  of  food,  drink  and  housing. 

Paratyphoid  fevers  are  present  in  all  seasons.  But 
their  curve  is  usually  superimposed  upon  that  of  typhoid 
fever.  It  reaches  its  highest  level  in  the  months  of 
August,  September  and  October,  i.e.  during  the  hot 
period. 

According  to  certain  authors,  the  gravest  forms  are 
observed  in  winter. 

All  ages  are  susceptible,  smce  young  children,  and 
even  infants,  may  be  attacked  by  paratyphoid  as  well 
as  old  men.  The  two  sexes  are  affected  in  the  same 
proportion. 

Paratyphoid  fever,  either  from  its  high  contagiosity 
or  as  the  result  of  ordinary  conditions  of  infection, 
fairly  often  appears  in  small  local  or  family  epidemics, 
which  may  be  very  mild,  or,  on  the  contrary,  severe. 
Its  incubation  period  is  generally  from  nine  to  fifteen 
days. 


256    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Etiology  of  Paratyphoid  Fevers. 

The  chief  causes  of  paratyphoid  fevers  A  and  B  are 
the  same  as  those  of  typhoid  fever. 

The  paratyphoid  bacilli  gain  entrance  to  the  organism 
by  the  alimentary  canal,  reach  the  blood  (where  they 
are  found  on  cultivation),  and  multiply  in  the  lymphoid 
organs,  spleen,  bone-marrow,  viscera,  gall-bladder, 
etc.  The  bacilli  are  to  be  found  in  the  blood  during 
the  first  few  days  of  the  disease,  but  as  a  rule  they  stay 
there  a  shorter  time  than  the  typhoid  bacillus.  They 
are  discharged  in  large  quantities,  and  in  a  much  more 
continuous  and  regular  manner  than  the  typhoid 
bacilli,  in  the  excreta  and  urine.  The  mechanism  of 
their  elimination,  however,  is  the  same. 

As  in  typhoid  fever,  paratyphoid  bacilli  may  persist 
for  very  long  after  recovery,  either  in  the  faeces  or  urine. 
Tein])orary  or  chronic  paratyphoid  bacillus  carriers 
are  found  who  constitute,  with  the  patients  themselves, 
the  disseminating  agents  of  pathogenic  bacilli. 

The  average  proportion  of  carriers  among  those 
who  have  had  paratyphoid  fever  is  4  per  cent. 

Paratyphoid  bacilli  are  transmitted  by  the  excreta, 
urine,  pus  and  bronchial  secretions,  either  directly 
by  the  patient  or  carrier  to  the  healthy  subject,  or 
indirectly,  intermediaries  being  very  numerous,  as  in 
the  case  of  the  typhoid  bacillus. 

As  our  account  of  the  propagation  of  typhoid  fever 
applies  to  paratyphoid  fever  A  and  B,  the  present 
description  may  be  curtailed. 

Faecal  matter  is  the  most  dangerous  of  all  the  elements 
of  contagion.  This  is  why  direct  contagion  fairly  often 
affects  nurses,  visitors  and  patients  in  the  next  bed 
who  do  anything  for  them,  as  the  hands  are  the  most 
usual  means  of  conveyance.  They  become  con- 
taminated when  the  patients  are  being  attended  to, 
e.g.  when  they  are  given  a  bedpan  or  have  their  linen 
changed. 

In  like  manner,  by  depositing  their  excreta  on  the 
ground,  or  near  springs  and  wells,  or  vegetable  gardens, 


ETIOLOGY  OF  PARATYPHOID  FEVERS      257 

etc.,  temporary  or  chronic  carriers  contaminate  them, 
and  may  be  the  starting-point  of  epidemics  of  uncertain 
origin.  In  the  case  of  carriers  employed  as  cooks, 
the  absence  of  cleanliness  and  neglect  to  wash  the 
hands  are  equally  important  causes  of  infection  in 
families,  restaurants  and  houses,  barracks,  schools, 
refuges,  asylums,  etc. 

The  spread  of  contagion  by  food  is  certainly  very 
frequent.  But,  unlike  the  typhoid  bacillus,  which 
is  always  transmitted  in  such  cases  by  iood  which 
is  secondarily  affected  and  is  incapable  of  infecting 
animals,  paratyphoid  bacilli  may  readily  multiply  in 
animals,  giving  rise  to  diseases  the  nature  of  which 
is  not  always  suspected,  and  which  are  for  that  reason 
all  the  more  dangerous. 

Unlike  typhoid  fever,  which  is  an  exclusively  human 
disease,  paratyphoid  infections  or  Salmonelloses,  may 
affect  both  man  and  animals,  and  be  transmitted  from 
the  former  to  the  latter  and  vice  versa. 

According  to  Morgan,  Mori,  and  Gardenghi,  the 
alimentary  canal  of  domestic  animals  (dog,  cat,  rabbit, 
pig,  etc.)  may  contain  paratyphoid  bacilli,  and  there- 
fore the  fsecal  matter  of  animals,  as  well  as  human 
excreta,  may  serve  as  the  means  of  conveying  the 
paratyphoid  A  or  B  bacillus. 

So,  if  this  observation  is  correct,  animals  may 
become  actual  carriers  of  paratyphoid  organisms. 

On  the  other  hand,  the  pig,  ox,  cow,  calf,  and  much 
less  frequently  the  sheep  (Babes)  and  the  horse,  may  be 
infected  by  bacilli  belonging  to  the  group  of  Salmonel- 
loses, which  includes  closely  related  micro-organisms, 
especially  B.  enteritidis,  which  is  most  frequently 
found  in  food-poisoning.  This  bacillus  causes  in  animals 
a  rapidly  fatal  septicaemia,  infective  gas tro -enteritis 
with  profuse  diarrhoea  (in  the  calf),  arthritis,  metritis 
(in  the  cow),  and  closely  resembles  the  paratyphoid  B 
bacillus.  Its  pathogenic  characters  and  reaction  on 
sugar  media  are  the  same.  Experimental  or. human 
serum,  however,  which  agglutinates  one  of  these  micro- 
organisms, does  not  definitely  agglutinate  the  other. 


258    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

There  is,  therefore,  a  reason  for  separating  them, 
especially  as  the  symptoms  which  they  cause  in  man 
are  somewhat  different. 

Direct  contagion  by  paratyphoid  bacilli  is,  therefore, 
liable  to  be  transmitted  not  only  from  nran  to  man 
under  the  same  conditions  as  the  typhoid  bacillus, 
but  also  from  diseased  or  healthy  animals  (carriers) 
to  man,  and  doubtless  vice  versa. 

The  factors  of  indirect  contagion  are  necessarily 
also  at  work  in  the  propagation  of  paratyphoid  bacilli. 
They  act  more  frequently  than  in  typhoid  fever, 
because  paratyphoid  A  and  B  bacilli  are  much  more 
resistant  than  the  typhoid  bacillus  to  external  causes  of 
destruction.  They  are  more  long-lived  than  the  typhoid 
bacillus.  They  may  persist  longer  in  water  and 
putrefying  media  like  meat,  in  which  the  typhoid 
bacillus  does  not  survive. 

Drinking-water  has  frequently  been  accused  of  con- 
veying the  paratyphoid  bacillus.  Examples  have 
been  given  by  Sacquepee  and  Chevrel,  and  by  Darde. 
Chevrel  recorded  in  his  thesis  a  mild  epidemic  of  twenty- 
five  cases  of  paratyphoid  fever  B  which  occurred  after 
drinking  the  water  from  a  cistern. 

The  injurious  effect  of  drinking-water  has  been 
proved  at  Rennes,  as  well  as  in  Germany,  Austria,  the 
United  States,  etc. 

The  use  of  impure  cider  prepared  with  contaminated 
water  was  incriminated  in  an  epidemic  which  attacked 
the  35th  artillery  regiment  in  1908,  and  gave  rise  to 
fifty-four  cases  (Follin  and  Fortineau). 

In  most  of  these  epidemics  the  paratyphoid  B  bacillus 
was  concerned. 

Meat  is  still  more  frequently  the  starting-point  for 
infections  due  to  paratyphoid  bacilli.  These  food 
infections,  of  which  Polin  and  Labit  and  Sacquepee 
have  given  a  very  complete  description,  have  sometimes 
a  sudden  and  almost  immediate  onset,  with  symptoms 
of  acute  gastro -enteritis  which  may  simulate  cholera, 
and  sometimes,  on  the  contrary,  a  normal  incubation 
with   a   more   typical   course.     The   immediate   onset 


ETIOLOGY  OF  PARATYPHOID  FEVERS      259 

of  symptoms  has  been  attributed  to  intoxication  by 
thermostabile  poisons  developed  in  putrefying  meat 
or  coming  from  diseased  animals  :  it  has  also  been 
thought  that  putrefying  meat  contained  toxic  nitrites 
which  might  cause  these  rapid  symptoms. 

The  later  infective  symptoms  are  due  to  infection 
by  the  paratyphoid  bacillus,  Geertner's  bacillus,  or 
another  representative  of  the  group  of  Salmonelloses. 

The  contagious  character  of  meat  is  explained  by 
what  we  have  said  with,  regard  to  the  latency  of  the 
paratyphoid  B  bacillus  in  the  pig's  intestine.  In 
Germany  bacilli  belonging  to  the  group  of  Salmonelloses 
are  extremely  common  in  pigs'  intestines :  7  per 
cent,  of  the  animals  contain  them,  and  sausages  made 
with  pigs'  meat  are  also  infected  with  the  paratj^^phoid 
B  bacillus. 

It  is  in  Germany,  therefore,  that  the  largest  number 
of  epidemic  cases  of  paratyphoid  fever  have  been  seen 
following  the  ingestion  of  meat  from  diseased  animals. 

The  possibility  of  infection  can  only  be  allowed 
when  the  meat  (pork,  beef,  or  veal)  has  been  insuf- 
ficiently cooked.  According  to  VaUin,  the  central 
temperature  of  roast  meat  does  not  often  exceed 
45-50°  C. ;  in  hams  weighing  5  kilogrammes  the 
central  temperature  does  not  reach  60°  C.  after  three 
hours'  cooking.  Now;  typhoid  bacilli  are  Idlled  only 
at  a  minimum  temperature  of  57-58°  C.  prolonged 
for  an  hour.  When  infected  food  is  given  raw  or  half 
cooked  to  animals  such  as  a  monkey  (van  Ermengem), 
dog,  mouse,  guinea-pig  or  rabbit,  a  similar  infection 
may  result. 

The  remarkable  power  of  resistance  of  typhoid 
bacilli  explains  how  it  is  that  after  the  death  of  the 
infected  pig,  ox  or  calf,  the  hacillus  continues  to  multiply 
rapidly,  especially  in  summer  time,  in  pieces  of  meat, 
and  also  to  secrete  abundant  toxines  whose  presence 
explains  the  symptoms  which  appear  almost  im- 
mediately. In  this  respect  investigations  made  with 
B.  enteritidis  are  conclusive.  Persons  who,  under  the 
impression   that   it   was   wholesome,    partook   of   the 


260    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

meat  of  some  animals  inoculated  with  the  bacillus  of 
the  Morseele  epidemic,  were  all  attacked  with  gastro- 
enteritis. When  kept  in  the  ice -chest,  the  meat  of 
these  animals  is,  for  this  reason,  much  less  dangerous. 

The  consumption  of  pork-butchers'  meat,  galantine 
(Netter),  meat  pies,  black  puddings,  sausages  of  any 
kind,  etc.,  has  been  the  occasion  of  numerous  cases 
of  paratyphoid  B  fever.  Further,  as  we  have  already 
said,  it  has  frequently  been  possible  to  isolate  the 
paratyphoid  bacillus,  by  cultivation,  from  the  inside 
of  sausages  or  pies  made  with  minced  meat,  or  brawn. 
Organisms  so  isolated,  in  spite  of  their  presenting  the 
characters  of  paratyphoid  bacilli,  are  not  always 
pathogenic  to  the  animals  who  are  made  to  swallow 
them.  Perhaps  in  such  cases  their  virulence  has 
disappeared  or  become  attenuated. 

It  appears  certain  that  when  fresh  meat  gives  rise 
to  a  large  epidemic,  the  meat,  which  had  been  consumed 
shortly  after  slaughtering,  came  from  diseased  animals 
infected  by  the  bacillus.  In  a  total  of  fifty-one  epi- 
demics of  Salmonelloses,  Sacquepee  found  that  nine 
were  due  to  pork,  seven  to  veal,  and  seven  to  beef. 
The  meat  of  diseased  poultry  has  sometimes  been 
incriminated. 

Leaving  aside,  however,  the  infections  due  to  B. 
enteritidis,  which  are  more  common,  but  which,  perhaps, 
should  not  be  considered  strictly  as  paratyphoid 
infections,  it  is  none  the  less  certain  that  paratyphoid 
bacilli  may  be  transmitted  by  meat  which  is  uncooked 
or  is  insufficiently  sterilised  by  cooking.  Meat  pies, 
pork-butchers'  meat,  etc.,  may  have  themselves  been 
contaminated  secondarily,  when  the}^  were  being  pre- 
pared in  the  kitchen,  by  a  carrier's  unclean  hands ; 
by  contaminated  instruments,  vessels  or  tables ;  by 
the  numerous  flies  which  convey  the  micro-organism ; 
by  ice,  etc. 

In  other  cases  the  paratyphoid  bacillus  may  be 
present  in  the  intestine  of  the  animal  itself,  and  con- 
taminate the  sound  meat  when  the  carcase  is  being 
cut  up.     When  the  external  temperature  is  high,  the 


PROPHYLAXIS  OF  PARATYPHOID  FEVERS    261 

bacilli  also  find  a  satisfactory  culture -medium,  and 
TCL2iY  multiply  with  extraordinary  rapidity  in  mince, 
saveloys,  sausages,  pies,  etc.,  all  the  more  so  as  they 
are  facultative  anaerobes.  This  is  the  explanation  of 
infections  following  the  consumption  of  these  foods. 
Preserved  pork,  ham  (Pottevin),  corned  beef,  dried 
goat's  meat,  sausages  and  pates  de  foie  gras,  galantine, 
etc.,  have  given  rise  to  such  cases. 

Contamination  by  hands,  flies,  ice  and  tables  or 
vessels  which  have  been  used  for  infected  food  or 
meat  furnishes  an  explanation  of  the  cases  of  para- 
typhoid fever  or  fever  due  to  B . ,  enteritidis  occurring 
after  consumption  of  fish,  semolina,  vermicelli,  cakes, 
beans,  etc.  Cream  has  also  given  rise  to  similar 
digestive  disturbances.  But  in  that  case  the  micro- 
organism may  have  been  brought  by  the  milk. 

Cases  of  epidemic  paratyphoid  fever  are  on  record 
following  the  use  of  milk  (unboiled).  Max  Levine 
and  Fred.  Eberson  have  related  a  similar  case  in  the 
College  of  Ames,  Iowa.  The  milk  had  been  con- 
taminated by  the  hands  of  a  carrier  or  a  convalescent 
who  had  been  milking  cows  and  bottling  the  milk. 

Oysters,  mussels,  cockles,  and  other  shell -fish  are 
an  equally  frequent  cause  of  paratyphoid  contagion. 
Cases  of  this  disease  due  to  consumption  of  ordinary 
oysters,  or  so-called  Portugal  oysters,  appear  to  be 
becoming  more  frequent,  owing  to  the  deplorable 
habit  of  those  who  own  or  lay  oyster  beds  of  keeping 
them  in  harbours,  in  water  infected  by  feecal  matter 
and  sewer -water. 

Prophylaxis  of  Paratyphoid  Fevers 

The  prophylactic  measures  relating  to  paratyphoid 
fevers  A  and  B  are  identical  with  those  of  typhoid  fever 
properly  so  called,  but  they  also  demand  a  special 
hygienic  supervision  of  slaughtered  meat,  of  insuf- 
ficiently sterilised  and  preserved  meats,  vegetables 
and  fish,  as  well  as  of  all  forms  of  pork-butchers'  meat, 
because  infection  may  be  spread  by  the  meat  of  diseased 


262    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

animals,  or  their  excreta,  or  the  faeces  of  domestic 
animals  who  may  be  actual  carriers  of  the  paratyphoid 
B  bacillus. 

In  the  civil  population,  as  in  the  army,  complete 
cooking  or  effective  sterilisation  of  preserved  food  of 
all  kinds,  prevents  this  special  mode  of  contagion  by 
destroying  the  paratyphoid  bacilli,  which  are  killed 
at  60°  C.  Milk  ought  not  to  be  taken  until  it  has  been 
boiled.  Lastly,  food  of  any  kind,  whether  sterilised 
or  not,  may  become  a  cause  of  contagion,  through 
being  handled  by  carriers  or  exposed  to  contagion  by 
flies.  It  is  important,  therefore,  to  find  the  carriers 
and  to  remove  them  from  any  culinary  employment 
in  boarding-houses,  hospitals,  asylums,  etc.,  as  well 
as  in  the  army,  both  in  peace  and  war  time  (kitchen, 
canteens).  It  will  be  wise  to  examine  the  stools  of 
those  who  have  had  a  paratyphoid  fever  before  giving 
them  employment  of  this  kind.  Persons  who  suffer 
from  chronic  hepatic  or  biliary  lesions,  such  as  jaundice 
or  gallstones,  are  often  open  to  suspicion ;  useful 
information  can  be  obtained  by  examination  of  their 
stools. 

We  will  not  dwell  any  longer  on  the  prophylaxis  of 
paratyphoid  fevers,  but  will  refer  our  re'aders  to  what 
we  have  said  in  the  chapter  devoted  to  the  prophylaxis 
of  typhoid  fever. 

To  facilitate  this  prophylaxis  the  notification  of 
paratyphoid  tevers  should  be  made  compulsory. 

For  paratyphoid  fevers  A  and  B,  as  for  typhoid 
fever,  vaccination  constitutes  the  best  prophylactic 
measure. 


CHAPTER    XVII 

ANTITYPHOID    AND    ANTIPARATYPHOID   VACCINATION 

The  prophylaxis  ot  typhoid  and  paratyphoid  fevers 
has  been  most  successfully  completed  by  active  im- 
munisation against  these  infectious  diseases.  It  may 
be  said  that  considerable  progress  occurred  as  soon 
as  this  preventive  method  was  introduced  into  practice 
in  the  civil  population  and  the  army.  Numerous 
articles,  to  which  there  is  no  need  to  allude,  have 
appeared  on  this  subject. 

Human  vaccination  was  preceded  by  an  experimental 
period.  The  principle  of  immunisation  by  living  or 
dead  cultures  or  their  soluble  products  was  established 
by  Pasteur  in  the  case  of  anthrax  and  fowl-cholera, 
and  has  since  been  extended  by  a  large  number  of 
scientists  to  anthrax  (Toussaint,  Chauveau),  sympto- 
matic anthrax  (Arloing,  Cornevin  and  Thomas),  the 
bacillus  of  malignant  oedema  (Roux  and  Chamber- 
land),  the  bacillus  pyocyaneus  (Bouchard  and  Charrin), 
the  bacillus  of  hog  cholera  (Theobald  Smith,  Salmon), 
etc.,  and  lastly,  in  1888  and  1892,  to  the  typhoid  bacillus 
by  cultures  heated  to  a  temperature  of  120  or  100°  C. 
by  Chantemesse  andWidal,and  to  50°  C.  by  Bruschettini 
(1892),  etc.  Most  of  these  authors  used  heat  to  kill 
the  virus.  T.  Smith  and  Salmon,  as  long  ago  as  1886, 
immunised  animals  against  hog  cholera  by  several 
injections  of  cultures  heated  to  58°  C,  a  temperature 
which  did  not  impair  the  vaccine.  The  vaccination 
of  man  against  typhoid  fever  is  consequently  due  to 
Pasteurian  methods. 

Almost  at  the  same  period,  i.e.  in  1896,  Pfeiffer  and 
Kolle  on  the  one  hand,  and  A.  E.  AVright  on  the  other, 

263 


264    TYPHOID  FEVER  4ND  PARATYPHOID  FEVERS 

applied  to  man  vaccination  against  typhoid  fever  by 
heated  cultures.  As  a  matter  of  fact,  it  is  the  English 
scientist,  A.  E.  Wright,  who  is  the  true  initiator  of  this 
method  in  man  rather  than  Pfeiffer  and  Kolle,  who 
made  no  extensive  use  of  the  method,  whereas  A.  E. 
Wright  applied  it  in  the  English  Army  to  a  large 
number  of  individuals  with  very  successful  results. 

Wright  first  of  all  made  use  of  broth  cultures  ten  to 
twelve  days  old,  sterilised  at  60°  C.  with  the  addition 
of  0-5  per  cent,  of  lysol.  Subsequently  the  duration 
of  the  cultures  was  reduced  to  forty-eight  hours,  and 
the  temperature  of  sterilisation  to  53°  C.  (Leishman). 
But  the  bacillus  was  not  quite  killed  at  this  tempera- 
ture ;  the  addition  of  lysol  finally  destroyed  it.  Three 
injections  were  made,  the  first  consisting  of  500  million 
bacilli,  the  second  1000  millions,  and  the  third  of 
1500  millions. 

After  the  publication  in  London  of  the  Report  of 
the  Antityphoid  Committee,  according  to  which  cultures 
heated  above  65°  C.  lose  their  immunising  efficacy, 
the  sterilisation  has  been  carried  out  at  a  lower 
temperature. 

The  vaccine  employed  in  the  United  States  since 
1909  is  that  of  Russell,  prepared  in  the  laboratory  of 
the  Army  Medical  School. 

The  bacilli  are  grown  on  agar  for  twenty  hours, 
washed  ofi  with  normal  saline  solution  and  then  killed 
by  heating  to  55-56°  C.  for  seventy-five  minutes.  A 
solution  of  1  in  100  tricresol  is  then  added.  The 
vaccine  contains  1000  million  bacilli  per  c.c.  It  is 
employed  in  the  American  Army  and  Navy. 

The  vaccine  prepared  by  Chantemesse  is  made  in 
the  same  way  as  in  the  United  States,  0-25  per  cent, 
of  cresol  being  added.  It  is  used  in  the  French  Navy. 
Four  injections  are  given.  The  doses  injected  are 
0-25  c.c,  0-50  c.c,  0-75  cc  and  1  c.c. 

Le  Moignic  and  Pinoy  have  recommended  a  vaccine 
made  with  killed  baciUi  suspended  in  sterilised  oil. 

Renaud  has  proposed  a  vaccine  which  has  been 
exposed  for  thirty  minutes  to  the  rays  of  a  quartz  lamp. 


VACCINATION  265 

Lumiere  and  Chevrotier  have  proposed  a  dried  and 
pulverised  mixture  of  typhoid  bacilli,  B.  coli  and  para- 
typhoid bacilli  killed  by  heat.  The  powder  is  made 
up  into  keratinised  pills  which  are  swallowed. 

Castellani  was  the  first  to  attempt  vaccination  with 
living  cultures ;  310  persons  were  given  cultures  which 
were  first  attenuated  at  a  temperature  of  50°  C,  and 
then  normal  ones.  Three  or  more  injections  were 
given.  NicoUe,  of  Tunis,  also  used  living  cultures 
which  had  undergone  two  washings,  the  first  a  complete, 
and  the  second  an  incomplete  one ;  the  turbid  super- 
i^atant  fluid  containing  14  million  bacilli  per  c.c. 
Intravenous  injections  of  this  vaccine  are  given,  the 
first  containing  400  millions,  the  second  1200  millions. 
,  Besredka's  method  is  founded  on  the  use  of  a  living 
sensitised  vaccine.  The  typhoid  bacillus  is  cultivated 
for  forty-eight  hours  on  agar,  washed  in  saline,  and 
then  treated  with  antityphoid  serum.  After  remaining 
in  contact  with  it  for  twenty-four  hours,  the  living 
bacilli  are  decanted  and  washed  and  emulsified  in 
normal  saline.  This  vaccine  contains  1000  million 
bacilli  per  c.c. :  1  c.c.  is  first  injected,  and  then  2  c.c. 

The  use  of  living  vaccines  does  not  appear  to  have 
become  general.  The  objections  to  it  are  (1)  the  possi- 
bility of  those  using  it  contracting  typhoid  fever, 
(2)  of  overworked  or  enfeebled  subjects  becoming 
infected  with  an  immediate  or  delayed  growth  of  the 
bacillus  in  their  biliary  passages,  (3)  the  creation  of 
carriers.  The  employment  of  a  dead  virus  has 
therefore  been  more  generally  adopted. 

It  is  possible  to  kill  the  tjrphoid  bacillus  by  other 
means  than  heat,  especially  antiseptics*.  We  have,  in 
fact,  seen  that  the  vaccine  of  Wright  and  Leishman  is 
much  attenuated  by  a  temperature  of  53°  C.  and  is 
killed  by  lysol.  Semple  has  recommended  carbolic 
acid  (5  per  1000)  which  has  recently  been  employed 
in  the  Italian  army. 

Banque  and  Senez  have  proposed  the  employment 
of  a  vaccine  sterilised  by  iodine,  which  has  been  in 
use  especially  at  Marseilles. 


266    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

The  use  of  a  vaccine  sterilised  by  ether  (H.  Vincent) 
is  founded  on  the  principle  that  the  typhoid  bacillus 
and  micro-organisms  belonging  to  the  same  group  are 
very  sensitive  to  the  action  of  ether.  The  typhoid 
bacillus  is  lolled  by  ether  in  thirty-five  or  forty  minutes 
on  the  average.  Ether  also  possesses  the  advantage  of 
removing  the  fatty  substances  which  are  present  in 
large  quantities  in  the  protoplasm  of  the  bacilli  and 
serve  to  make  the  vaccine  painful  and  fever-producing. 

Vincent's  vaccine  is  made  of  ten  strains  of  typhoid 
bacilli  of  different  origin,  which  makes  it  polyvalent. 
Strains  of  paratyphoid  bacilli  A  and  B  have  been 
associated  with  them  from  the  first,  i.  e.  since  1910 
{triple  vaccine). 

The  antityphoid  vaccine  as  first  used  in  the  army 
was  inoculated  in  successive  doses  of  05  c.c,  1  c.c, 
1"5  c.c.  and  2  c.c,  but  the  number  of  injections  was 
first  reduced  to  three  and  then  to  two.  Thus,  in  1913, 
26,000  soldiers  were  vaccinated  with  three  injections 
each,  in  the  XlVth  legion  with  excellent  preventive 
results.  The  total  number  of  bacilli  injected  has 
varied  from  1600  to  1800  millions. 

Lastly,  there  has  long  been  a  question  as  to  whether 
antityphoid  vaccination  could  not  be  simplified  under 
war  conditions.  In  the  Official  Report  presented  in 
April  1914  to  the  Committee  of  the  International  Health 
Office,  H.  Vincent  concluded  that  under  these  circum- 
stances a  modified  vaccination  consisting  of  only  two  in- 
jections of  antityphoid  vaccine  should  be  performed  with 
somewhat  stronger  doses  ;  the  immunity  thus  conferred 
being  obviously  less  powerful  and  less  prolonged. 

This  method  was  proposed  and  carried  out  at  the  be- 
ginning of  the  war,  and  in  1915  in  the  French  army  at  the 
Front.  The  English  army  have  also  used  it  with  heated 
vaccine,  repeating  the  injections  at  the  end  of  a  year. 

What  is  the  quantity  of  vaccine  needed  to  confer 
immunity,  and  what  is  the  duration  of  this  immunity  ? 
As  a  matter  of  fact,  the  immwiity  and  its  duration  are 
in  direct  relation  not  to  the  number  of  the  injections, 
nor  even,  properly  speaking,  to  the  quantit}'^  of  vaccine 


VACCINATION  267 

injected,  but  to  the  number  of  typhoid  bacilli  inoculated. 
The  degree  of  virulence  of  the  bacilli  has  no  influence. 
The  technique  of  preparing  the  vaccines  should  not 
aim  at  acting  violently  on  the  bacilli.  Any  pronounced 
modification,  whether  natural  or  artificial,  of  the  micro- 
organisms weakens  or  destroys  their  powers  of  pro- 
ducing immunity,  e.  g,  a  temperature  above  60°  C, 
certain  antiseptics,  oxidising  agents,  etc. 

A  dose  of  500  to  1000  million  typhoid  or  paratyphoid 
bacilli  killed  by  ether  confers  a  considerable  immunity, 
or  considerably^  attenuates  the  gravity  of  the  injection. 
The  number  of  cases  of  typhoid  fever  which  may  occur 
during  the  year  following  an  injection  of  1300-1500 
million  bacilli  killed  by  ether  is  0*50  per  1000  on  the 
average  in  a  highly  infected  population.  The  duration 
of  the  immunity  conferred  by  this  close  is  from  one 
to  two  years  on  the  average.  The  immunity  may  be 
affected  by  the  degree  of  enfeeblement  or  overwork  of 
the  individuals  who  have  been  exposed  to  contagion. 

The  minimal  protecting  dose  of  antigen  is  between 
1300  and  2000  million  typhoid  bacilli.  With  a  dose 
of  3000  millions  experience  has  shown  that  the  propor- 
tion of  cases  of  typhoid  fever  in  the  vaccinated  who 
have  been  very  much  exposed  to  contagion  is  about 
0- 25-0- 35  per  1000.  The  injection  of  4000-5000 
million  bacilli  killed  by  heat  considerably  reduces  the 
susceptibility,  even  in  soldiers  who  are  engaged  in 
fighting  and  are  suffering  from  exhaustion.  One 
frequently  meets  with  a  series  of  20,000  vaccinated 
soldiers  and  more  who  have  been  exposed  to  contagion, 
and  do  not  show  a  single  case  of  typhoid  fever. 

The  duration  of  the  immunity  resulting  from  the 
inoculation  of  3000-5000  million  of  typhoid  bacilli 
killed  by  ether  exceeds  four  years,  according  to 
experience  in  Morocco,  and  it  is  very  probable  that 
in  many  of  those  who  have  been  vaccinated  in  this  way 
it  may  persist  throughout  life,  thus  resembling  the 
immunity  conferred  by  an  attack  of  typhoid  fever. 

What  we  have  called  the  "  protecting  dose  "  is 
weaker  in  the  case  of  the  paratyphoid  bacUli  A  and  B 


268    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

than  in  that  of  the  typhoid  bacillus.  Considerable 
immunity  is  obtained  by  1000  and  still  more  so  by 
1500  million  of  paratyphoid  bacilli  killed  by  ether. 

It  is  obvious,  therefore,  that  there  is  no  need  to  inject 
excessive  quantities  of  antigen  to  obtain  protection 
against  typhoid  and  paratyphoid  fevers. 

Mixed  Vaccination. 

The  nature  of  the  vaccination  should  obviously 
depend  on  that  of  the  epidemic  diseases  which  one  has 
to  fight.  In  epidemics  in  which  t^^hoid  fever  is  the 
only  disease,  antityphoid  vaccine  is  used. 

The  co-existence  of  paratjqjhoid  fevers  in  the  same 
community  which  has  been  exposed  to  contagion 
should  entail  the  use  of  a  mixed  vaccine  or  the  succes- 
sive injections  of  different  vaccines.  Both  methods  have 
been  employed  in  the  French  army  mth  similar  results. 

CasteUani  has  vaccinated  a  certain  number  of  persons 
against  typhoid  and  paratyphoid  fevers,  and  also 
against  dysentery  or  cholera  simultaneously  by  means 
of  mixed  vaccines. 

It  is,  however,  the  double  vaccine  antiparatyphoid 
A  and  B  or  the  triple  vaccine  antityphoid  and  anti- 
paratyphoid  A  and  B,  which  are  most  commonly 
employed. 

The  triple  vaccine  designated  by  the  name  of  T.A.B. 
vaccine  (ether  vaccine)  was  first  employed  in  the  French 
army  in  1910-1911.  The  same  mixed  vaccine  was 
used  in  1911  at  the  time  of  the  first  official  application 
of  vaccination  in  East  Morocco.  Some  was  sent  in 
1912  for  use  in  the  sections  of  the  hospital  orderlies, 
as  well  as  in  several  garrisons  of  the  Metropole  army 
at  Casablanca  and  Oudjda.  Vaccination  with  the 
triple  vaccine,  or  T.A.B. ,  was  repeated  in  East  Morocco 
in  1913  and  1914.  Since  October  1914  the  triple  ether 
vaccine  has  also  been  used  on  a  large  scale  by  E.  Sergent 
and  L.  Negre,  more  than  100,000  men  being  vaccinated 
among  the  troops  stationed  in  Algeria. 

Its  use  has  become  more  extensive  since  statistics  have 
shown  the  relative   frequency  of   paratyphoid   fevers 


VACCINATION  269 

among  the  armies  fighting  at  the  Front  in  the  present 
war. 

Lastly,  the  same 'triple  vaccine,  or  T.A.B.,  sterilised 
by  ether  and  prepared  at  the  Institute  of  Milan,  was 
employed  in  1912  and  1913  among  the  Italian  troops 
fighting  in  Libya  and  Cyrenaica,  as  well  as  in  the 
garrison  of  Brescia  and  at  Careno  (F.  di  Cavellerleone, 
Santoliquido)  with  the  most  strildng  results. 

Ever  since  the  year  1911,  successive  attempts  have 
been  made  in  the  French  army,  with  varying  propor- 
tions of  typhoid  and  paratyphoid  bacilli,  to  determine 
the  best  composition  of  the  triple  vaccine,  that  is  to 
say,  the  one  which  combines  the  minimum  reaction 
with  the  maximum  immunity. 

The  mixed  vaccine  first  employed  in  the  French  army 
contains  560  millions  of  typhoid  bacilli  per  c.c.  plus 
250  millions  each  of  paratyphoid  bacilli  A  and  B. 
Vaccination  at  present  is  performed  with  two  injections 
of  a  vaccine  containing  per  c.c.  1000  million  typhoid 
bacilli  and  500millionsof  eachof  the  paratyphoid  bacilli. 

Experience  has  shown  that  a  more  concentrated  form 
of  this  ether  vaccine  may  be  used  without  causing  more 
numerous  reactions.  A  single  injection  of  a  larger  dose 
may  be  given.  The  quantitative  estimation  of  the 
bacilli  is  made  at  the  Army  Laboratory  for  the  various 
vaccines,  typhoid,  paratyphoid  A  and  B,  or  T.A.B.,  by 
means  of  the  opacity-meter  with  rays  selected  by  Vles,^ 
tutor  at  the  laboratory. 

^  The  principle  of  this  apparatus  is  as  follows.  Two  luminous 
circuits  derived  from  the  same  source  traverse,  one  the  vaccine  to 
be  tested,  and  the  other  an  absorbing  system  (polarisation  system) 
by  means  of  which  one  can  vary  the  intensity  of  the  circuit.  The 
rays  traverse  a  coloured  screen  which  allows  only  the  red-orange 
light  (A  615)  to  pass.  The  rays  constituting  the  two  circuits  form 
two  juxtaposed  images  in  the  eye-piece  of  the  same  glass.  The 
equalisation  of  the  two  portions  of  the  field  is  established  as  in  a 
photometer,  and  the  graduation  is  read  off.  The  latter,  which 
depends  upon  the  absorbing  system,  indicates  the  amount  of  bacteria 
in  the  vaccine  examined,  owing  to  the  previous  standardisation. 
This  apparatus  also  allows  one  to  determine  what  solution  should 
be  made  in  the  stock  emulsion  of  bacilli  to  obtain  a  vaccine  with 
100,000  bacteria  per  c.c. 


270    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

This  apparatus  is  exactly  standardised  against 
emulsions  of  bacilli  in  suspension  in  normal  saline 
solution,  whose  quantity  of  bacilli  has  been  determined 
by  a  previous  count. 

The  Army  Laboratory  also  prepares  antiparatyphoid 
A  or  B  vaccines,  and  mixed  vaccines  A  and  B,  the 
former  containing  500  millions  and  the  latter  1000 
millions  (500  millions  of  each  bacillus).^ 

In  addition  to  the  simple  antityphoid  vaccine 
Chantemesse  and  Widal  also  employ  the  triple  heated 
vaccine  (antityphoid  and  antiparatyphoid  A  and  B), 
which  contains  1500  million  bacilli  per  c.c.  Four 
injections  are  given  with  the  following  doses,  1  c.c, 
1"5  c.c,  2  c.c,  3  c.c  When  circumstances  require  it, 
three  injections  are  given  in  doses  of  1*25  c.c,  2  c.c, 
and  2-5  c.c.  The  triple  heated  vaccine,  No.  2,  is 
injected  twice  in  doses  of  1  c.c  and  2  c.c  respectively. 
It  contains  3,300,000,000  bacilli  or  1100  millions  of 
each  of  the  typhoid  and  paratyphoid  bacilli. 

The  lipo- vaccine  of  Le  Moignic  and  Pinoy  contains 
3000  million  bacilli  per  c.c  One  injection  only  is 
required. 

The  technique  of  injecting  the  vaccine  is  the  same  for 
all  vaccines  except  as  regards  the  region  chosen.  The 
injection  is  given  subcutaneously,  not  intra-muscularly, 
either  in  the  subclavicular  region,  or  on  the  outer  aspect 
of  the  deltoid  area,  or  behind  the  spine  of  the  scapula. 
The  last  site  has  been  chosen  because  it  is  less  rich  in 
nerves  and  vessels,  as  the  vaccine  may  sometimes 
penetrate  a  vessel  and  then  give  rise  to  an  almost 
immediate  febrile  reaction. 

Injections  should  be  carried  out  aseptically.  One 
should  make  certain  that  the  ampullae  are  hermetically 
sealed,  as  some  of  them  may  have  been  cracked  in 
transit. 

^  It  is  important  to  know  that  certain  glasses  have  a  consider- 
able alkaline  reaction  (0-010-0-018  per  litre  in  NaOH).  Vaccine 
prepared  or  kept  in  vessels  or  ampoules  made  of  this  glass  undergo 
bacteriolysis  and  becomes  much  clearer.  It  has,  nevertheless,  a 
normal  bacterial  content. 


VACCINATION  271 

Persons  who  have  been  vaccinated  should  be  in  a 
state  of  repose.  Fatigue  preceding  or  following  the 
injection  of  vaccine  is,  indeed,  an  important  cause  of 
post-vaccinal  fever.  It  is  also  accompanied  itself 
by  a  temperature  of  100-4°  F.  or  more  apart  from 
any  vaccination.  It  has  therefore  been  found  that 
vaccination  of  soldiers  at  the  Front  during  the  war 
sometimes  causes  much  more  numerous  febrile  reactions 
than  behind  the  lines.  These  reactions  are  most  pro- 
nounced in  men  who  have  come  back  from  the  trenches. 
On  the  other  hand,  after  a  rest  of  several  days,  they 
become  very  rare. 

It  has  fairly  often  happened  that  soldiers  who 
have  been  vaccinated  have  had  to  fight  a  few 
hours  after  the  injection,  without  any  complications 
developing. 

In  some  foreign  .armies  the  men  go  to  bed  after 
they  have  been  vaccinated.  This  practice  obviously 
diminishes  considerably  the  proportion  of  cases  with 
vaccinal  fever. 

Another  important  precaution  consists  in  making 
them  take'  only  a  light  meal  (tea  or  soup)  on  the  day 
of  injection.  Persons  who  have  eaten  to  excess  may 
suffer  from  vomiting  or  diarrhoea,  in  other  words, 
from  an  attack  of  indigestion  which  it  is  consequently 
possible  to  avoid. 

During  the  cold  season  precautions  should  be  taken 
to  prevent  the  soldiers  catching  a  chill  during  vaccina- 
tion. They  should  not  therefore  be  undressed  a 
long  time  in  advance,  and  they  should  wait  in  a  warm 
room.  In  vaccinated  persons  who  suffer  from  pain 
in  the  limbs  and  fever,  aspirin  in  doses  of  50  cgm. 
soon  causes  relief.  As  is  well  known,  this  drug  may 
produce  skin  eruptions,  more  rarely  fainting  attacks, 
or  transitory  anuria  in  predisposed  subjects.  Anti- 
pyrine  should  not  be  given,  as  it  is  a  more  frequent 
cause  of  these  symptoms. 

The  commonest  causes  of  a  febrile  reaction  following 
injection  of  vaccine  are  as  follows  :  (1)  Fatigue  or 
over-work;     (2)  Acute   alcoholism;     (3)  Too   large   a 


272    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

meal ;  (4)  Any  acute  concurrent  diseases,  and  certain 
chronic  diseases,  from  sore  throat  to  typhoid  fever  or 
paratyphoid  fever,  malaria,  influenza,  tuberculosis, 
etc. ;  (5)  Lastly,  but  not  invariably,  a  recent  attack 
of  typhoid  fever,  whether  unrecognised  or  not. 

It  is  well  to  insist  on  the  reaction  which  occurs  when 
vaccination  is  performed  on  persons  who  are  in  the 
incubation  stage  of  typhoid  fever  or  paratyphoid  fever, 
or  at  the  onset  of  these  diseases  or  suffering  from  an 
ambulatory  attack.  The  fever  which  appears  then 
is  analogous  to  that  which  is  caused  by  the  injection 
of  tuberculin  in  the  tuberculous,  or  of  mallein  in  those 
suffering  from  glanders.  In  war-time  when  typhoid 
diseases  are  so  common  in  the  non-vaccinated,  it  is 
important  to  be  familiar  with  all  those  causes  which 
determine  fever,^  so  as  to  refuse  or  postpone  vaccina- 
tion and  to  give  the  reactions  observed  their  true 
interpretation. 

A  large  number  of  reactions  seen  at  the  Front  are 
due  to  the  vaccination  of  persons  who  are  already 
invaded  by  typhoid  or  paratyphoid  bacilli.  It  may 
also  be  noted  that  many  subjects  who  have  been 
vaccinated  during  the  incubation  period,  escape  typhoid 
or  paratyphoid  fever,  thanks  to  the  injections,  having 
acquired  immunity  before  the  period  of  general 
infection. 

Accurate  observations  made  during  severe  epidemics 
like  those  at  Avignon,  Tours,  etc.,  have  shown  that 
when  the  vaccination  is  performed  at  the  beginning, 
or  even  in  the  middle  of  the  incubation  period,  the 
subject  has  a  good  chance  of  escaping  typhoid  fever. 

^  Some  medical  officers  who  had  observed  vaccinal  fevers  during 
an  epidemic,  thought  of  taking  the  temperatures  of  the  soldiers  to 
be  vaccinated  before  giving  the  injections,  during  epidemics  of 
typhoid,  paratyphoid,  influenza,  or  an  eruptive  fever.  The  ther- 
mometer showed  that  a  large  number  of  men  were  feverish  and 
were  already  suffering  from  one  or  other  of  these  diseases  (Rouget, 
Tournade,  etc.).  Identical  observances  have  been  made  during 
epidemics  of  influenza.  We  have  thus  an  explanation  of  a  large 
number  of  febrile  reactions,  which  are  not  caused  but  increased  or 
brought  to  light  by  the  vaccine. 


VACCINATION  273 

By  taking  the  simple  precautions  which  we  have  just 
described,  the  number  of  febrile  and  other  reactions 
following  vaccination  is  considerably  restricted. 

Consequently  the  actual  number  of  definite  contra- 
indications to  the  use  of  vaccination  is  limited. 

In  this  description  which  deals  exclusively  with  the 
practical  side  of  the  question,  it  is  necessary  to  state 
exactly  what  these  contra-indications  are. 

Some  are  temporary,  others  are  permanent.  The 
former  have  only  a  secondary  importance,  since  they 
mean  merely  a  postponement  of  the  injection.  It  is 
best,  therefore,  to  make  a  summary  medical  examina- 
tion of  the  subject  to  be  vaccinated,  and  if  he  is  ill  or 
worn  out,  to  put  him  off  till  the  following  week.  This 
procedure  enables  the  indisposition  or  acute  disease 
either  to  disappear  or  to  show  itself  in  its  true  colours. 
This  simple  precaution  very  often  saves  the  doctor 
injecting  a  patient  who  might  be  suffering  on  the  same 
day  from  an  acute  infection,  such,  as  pneumonia, 
meningitis,  or  an  eruptive  fever,  with  a  grave  prognosis, 
the  explanation  of  which,  as  has  sometimes  been  found, 
is  too  far  removed  from  the  truth. 

It  also  considerably  reduces  the  frequency  of  cases 
of  fever  by  exclusion  from  vaccination  of  persons  with 
slight  affections,  bronchitis,  sore  throat,  etc. 

Permanent  contra-indications  are  the  same  in  all 
countries  and  all  armies  (Wright),  viz.  severe  organic 
disease,  tuberculosis,  chronic  pleurisy,  with  or  with- 
out thoracic  deformity,  arterio -sclerosis  and  aortitis, 
myocarditis,  non-compensated  endocarditis,  diabetes, 
chronic  nephritis  with  signs  of  renal  insufficiency, 
hsematuria,  etc. 

Malaria  is  by  no  means  a  contra-indication,  with  the 
exception  of  acute  cases  or  malarial  anaemia  or  cachexia. 
In  Algeria,  Tunis,  Morocco,  Salonica  and  the  Belgian 
Congo,  where  malaria  is  very  frequent,  vaccination  is 
in  general  use  among  the  troops. 

The  only  precaution  consists  in  making  the  men 
with  chronic  malaria  undergo  a  quinine  cure  and  giving 
them  75  cgm.  or   1  gramme  of  quinine  on  the  day 


274    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

preceding  and  on  the  actual  day  of  the  injection. 
Experience  has  shown  the  possibility  of  a  return  of  a 
malarial  attack  when  this  precaution  is  neglected. 

There  is  no  harm  in  vaccinating  syphilitic  subjects. 
When  they  present  active  lesions  one  should  wait 
until  thej'"  clear  up  before  performing  vaccination. 
In  some  cases  one  may  be  at  a  loss  to  know  whether 
vaccination  should  be  performed.  A  trial  injection 
should  be  given  of  J  c.c.  of  antityphoid  or  antipara- 
typhoid  vaccine,  or  1  c.c.  of  the  T.A.B,  vaccine.  The 
temperature  should  be  taken  two  hours  later  and  on  the 
next  morning.  If  there  is  a  violent  reaction  one  should 
postpone  the  case  or  else  vaccinate  with  small  fractional 
doses.     This  trial  injection  wiU  be  of  great  service. 

The  vaccination  of  subjects  who  are  delicate  but 
without  any  visceral  lesions  is  quite  feasible.  It  is 
very  often  found  that  they  tolerate  injections  of  vaccine 
without  any  reaction. 

Recourse,  moreover,  may  be  had  to  the  fractional 
method  of  giving  weaker  and  more  frequent  doses, 
e.  g.  0*75  c.c,  when  the  case  is  not  urgent.  The  total 
number  of  bacilli  to  be  injected  must,  however,  be  given. 

Tuberculous  cases  in  which  the  process  is  stationary 
and  not  an  open  one,  may  be  vaccinated  if  the  general 
state  is  satisfactory,  care  being  taken  to  put  them  to 
bed  on  the  day  of  each  injection. 

It  has  been  said  that  antityphoid  vaccination  pre- 
disposes to  tuberculosis  and  pleurisy,  but  this  does  not 
appear  to  be  the  case. 

On  the  one  hand,  tuberculosis  is  much  rarer  in 
soldiers  in  Algeria,  where  typhoid  fever  is  frequent, 
than  in  France,  where  the  latter  disease  is  much  less 
widely  spread.  On  the  other  hand,  it  has  not  been 
found  that  a  larger  number  of  cases  with  acute  or 
chronic  tuberculosis  occur  among  vaccinated  than 
among  non- vaccina  ted  soldiers.  This  observation  has 
often  been  made  in  the  present  war. 

Vaccination  against  typhoid  fever  does  not  cause 
any  predisposition  to  paratyphoid  fevers,  scarlatina, 
measles,  cerebro -spinal  meningitis,  etc. 


VACCINATION  275 

Cardiac  cases  with  compensation  may  be  given  the 
benefit  of  vaccination  by  performing  it  in  the  manner 
already  described  by  means  of  small  and  more  numerous 
doses.  It  has  also  been  performed  with  ordinary 
doses  (H.  Vincent,  Bardot  and  Ledoux-Lebard,  etc.). 
But  it  should  not  be  done  in  the  case  of  patients 
suffering  from  lesions  of  the  aortic  orifice,  aneurysms, 
or  those  suffering  from  oedema,  dyspnoea,  etc. 

Patients  with  myocarditis  should  not  be  vaccinated. 
This  affection  should  be  sought  for  in  those  who  have 
previously  had  an  infectious  disease,  such  as  diphtheria, 
pneumonia,  broncho-pneumonia,  typhoid  lever,  etc. 

With  these  exceptions  it  may  l3e  maintained  that  the 
great  majority  of  persons  may  be  vaccinated  without 
any  harm. 

Even  advanced  age  is  not  a  contra -indication,  but 
diseases  or  lesions  of  the  viscera  and  arteries  may  be 
an  objection  to  vaccination. 

Subjects  of  fifty-five  or  sixty  years  of  age  have  been 
vaccinated  before  leaving  for  Morocco.  At  the  Front 
when  certain  villages  in  the  Argonne  had  been  invaded 
by  typhoid  fever,  the  children  and  the  youngest 
inhabitants  were  vaccinated.  As  typhoid  fever  then 
appeared  exclusively  among  the  aged,  they  were 
inoculated  also,  though  they  were  sixty  to  seventy  years 
of  age,  without  any  special  incident  occurring  (Combe). 

After  having  vaccinated  albuminuric  cases  mthout 
finding  any  aggravation  of  their  condition  or  fever  in 
consequence,  we  recommended  at  the  beginning  of 
1916  that  young  men  with  albuminuria  should  be 
vaccinated  when  they  had  no  symptom  of  renal  in- 
sufficiency. Observations  in  a  certain  number  of 
depots  (Paris,  Versailles,  Issoudun,  Perigiieux,  Libourne, 
etc.),  on  vaccination  with  the  triple  vaccine  or  T.A.B., 
showed  that  not  only  did  the  frequency  of  albuminuria 
not  increase  or  even  keep  at  the  same  level,  but  that 
it  actually  diminished  in  80  per  cent,  of  the  cases 
consisting  of  young  men  with  varying  degrees  of 
albumin  (from  mere  traces  up  to  0*50  gramme  or  1 
gramme  of  albumin). 


276    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

Among  141  albuminuric  cases  who  had  received 
four  injections  of  T.A.B.  vaccine,  examination  of  the 
urine  made  from  a  week  to  a  fortnight  after  the  last 
injection  by  the  regimental  medical  officers  or  dis- 
pensers showed  that  albuminuria  persisted  in  only 
twenty-one.  Vaccinations  of  this  kind  were  made  in 
a  large  number  of  other  cases  of  albuminuria  with 
similar  results  (Peyrot,  Fratelli,  etc.). 

It  is  obvious,  therefore,  that  T.A.B.  or  typhoid 
vaccine  has  no  effect  upon  the  normaJ  kidney.  Some 
cases  of  paroxysmal  hsemoglobinuria  received  the 
four  injections.  In  Morocco  German  prisoners  who 
had  previously  had  bilious  hsemoglobinuric  fever  were 
vaccinated  without  ill  effect.  Cases  of  nephritis, 
however,  with  oedema  or  symptoms  of  renal  in- 
sufficiency and  uraemia,  as  well  as  those  who  present 
symptoms  of  hypertension  associated  with  cirrhotic 
Iddney,  should  not  be  vaccinated. 

Widal  and  Mery  have  vaccinated  patients  in  hospital 
with  albuminuria  who  showed  none  of  the  severe 
functional  disturbances  of  Bright's  disease.  Some 
had  had  oedema,  and  one  had  had  11  grammes  of 
albumin  in  the  urine.  Inoculation  with  heated 
vaccine  was  made  under  favourable  conditions,  i.  e. 
in  hospital,  and  while  the  patients  were  enjoying  com- 
plete rest,  circumstances  which,  it  is  true,  do  not  occur 
in  military  practice.  Vaccination  did  not  cause  a 
return  of  the  oedema  nor  an  increase  in  the  nitrogenous 
retention.  One  of  the  patients  had  a  return  of  hse- 
maturia  four  days  after  each  of  the  two  injections. 

Widal  and  Mery  conclude  that  every  case  should  be 
postponed  in  which  there  is  a  recent  history  of  haema- 
turia  or  acute  nephritis,  or  in  which  there  has  been 
more  than  a  gramme  of  albumin  per  litre  or  more 
than  0*50  centigramme  of  urea  per  litre  of  blood 
serum. 

We  have  already  given  the  doses  of  heated  vaccine 
and  sensitised  vaccine  which  should  be  employed. 
The  doses  of  the  ether  vaccine  for  the  adult  are  as 
follows — 


VACCINATION  277 

1.  Vaccine  T  (antityphoid),  containing  500  million 
bacilli  per  c.c. 

{1st  injection  1    c.c. 
2nd        „         1^   „ 
3rd         „        2      „ 

or  if  reduced  vaccination  in  two  injections  is  performed — 

T5  J       ■,  •     ,.       r  1st  injection  1  c.c. 

Reduced  vaccination  ]  o  a  o 

In  less  vigorous  subjects  these  last  two  doses  should 
be  smaller,  viz.  0*75  c.c.  for  the  first,  and  IJ  c.c.  for 
the  second  injection.  But  it  goes  without  saying  that 
the  immunity  conferred  by  .reduced  vaccination  will 
be  correspondingly  weaker  and  less  lasting. 

Some  medical  officers,  guided  by  the  vigour  of  the 
subject,  have  given  two  injections  of  vaccine  T,  the 
first  consisting  of  Ij  c.c.  or  2  c.c.,  and  the  second  of 
2  c.c.  or  3  c.c,  without  observing  any  abnormal 
reactions  (Major  J.  Louis). ^ 

2.  Antiparatyphoid  A  and  B,  containing  500  millions 
of  each  of  the  bacilli  per  c.c. 

1st  injection  1^  c.c. 
2nd       „        2      „ 

3.  Triple  mixed  vaccine,  antityphoid  and  anti- 
paratyphoid  A  and  B  {T.A.B.  vaccine),  containing  500 
million  typhoid  bacilli  and  250  millions  of  each  of  the 
paratyphoid  A  and  B  bacilli. 

r  1st  injection  1^  c.c. 
Complete  vaccination  ^  q  j         "        o      " 
i^th         ';        2     I 

1  Some  soldiers  belonging  to  a  company  at  the  Front  received 
by  mistake  20  c.c.  of  the  same  vaccine  at  one  time — i.  e.  10-15 
thousand  million  bacilli — ^without  any  comphcations  beyond 
numerous  marked  febrile  reactions.  Of  course  this  is  not  an 
encouragement  to  imitate  this  practice.  An  instance  of  a  similar 
error  had  been  previously  published.  A  young  lady  who  had  been 
given  20  c.c.  and  two  children  who  had  been  given  10  c.c.  had 
a  moderate  febrile  reaction  (101-2°  F.),  but  severe  pain  locally 
(H.  Vincent). 


278    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

If  reduced  vaccination  is  performed,  the  first  three 
injections  should  be  given. 

Vaccination  has  been  performed  with  largie  doses  or 
with  ether  vaccine  of  high  potency  on  a  large  number 
of  soldiers,  in  two  injections  or  even  in  a  single  injec- 
tion. The  reactions  have  not  been  more  numerous 
and  the  preventive  results  have  been  excellent. 

As  has  been  said,  the  No.  2  ether  vaccine  contains 
2000  million  bacilli,  or  1000  million  typhoid  bacilli 
and  500  million  each  of  paratyphoid  A  and  B  bacilli. 
The  doses  to  be  injected  are — 

1st  injection  1|  c.c. 
2nd        „        2      „ 

The  dose  used  for  vaccination  with  a  single  injection 
is  2 1  c.c. 

Aiitityphoid  vaccination  and  antiparatyphoid  vac- 
cination, whether  separately  or  combined,  may  be 
performed  during  pregnancy  in  healthy  women,  and  in 
children.  Children  aged  two  years  and  even  eighteen 
months  have  been  inoculated. 

Children  tolerate  injections  of  vaccine  remarkably 
well. 

The  doses  of  antityphoid  vaccine  or  of  the  mixed 
vaccine  to  be  given  are  as  follows — 

Child  of  2-4    years  one-quarter  of  the  adult  dose. 
From      5-7       „     one-third  „  ,,         „ 

From      8-12     „      one-half  „  „         „ 

From    13-16     „     two-thirds        ,,  „         ,, 

In  giving  these  doses  the  state  of  development  of 
the  cMdren  should  be  taken  into  account.^ 

As  carried  out  under  normal  conditions  and  aseptic - 
ally  in  young  and  healthy  subjects  who  are  not  sujfering 
from  fatigue  or  incubating  a  disease,  mild  or  severe, 
and  in  conformity  with  the  ordinary  rules  (complete 

1  Children  11-12  years  of  age  were  vaccinated  with  the  T.A.B. 
vaccine  by  Dr.  Pilod  during  an  epidemic  in  the  army  zone  in  the 
north  of  France,  and  received  the  same  doses  as  the  adult  without 
ill  effects.  In  children  of  this  age,  therefore,  the  prescribed  doses 
may  be  increased  and  only  two  injections  given. 


VACCINATION  279 

rest  for  forty-eight  hours,  a  light  meal,  abstinence 
from  spirits  or  alcoholic  drinks),  injections  of  vaccine 
are  followed  by  a  relatively  small  number  of  febrile 
reactions,  which  is  on  the  average  2  per  cent.  The 
pains  in  the  limbs  and  headache  are  very  soon  relieved 
by  one  or  two  cachets  of  aspirin,  each  containing 
0*50  cgm.  Only  one  out  of  400  or  500  persons  has  a 
temperature  of  104°  F.,  and  even  that  is  not  always  the 
case.  Lastly,  it  may  happen  about  once  in  30,000 
injections  that  through  some  of  the  vaccine  penetrating 
a  vessel  there  is  immediate  absorption  of  the  vaccine, 
and  shivering,  fever,  headache  and  vomiting  at  once 
develop.  Rest  in  bed.  Riviere's  potion,  and  when 
the  vomiting  has  ceased,  small  doses  of  aspirin  (0*  IS- 
C'30  cgm.)  every  quarter  of  an  hour  cause  the  tem- 
perature to  drop  and  bring  the  symptoms  to  an  end. 
Some  vaccinal  reactions  accompanied  by  hypotension, 
may  be  successfully  treated  by  injection  of  J  milli- 
gramme *  of  adrenalin. 

Experience  gained  from  its  use  in  millions  of  indivi- 
duals proves  that  antityphoid  vaccination  is  inoffensive 
(Bousquet,  AmeuiUe  and  Brule,  Maurange,  Chalchat, 
etc.). 

Complications  have  been  observed  after  every  kind 
of  vaccine  in  the  armies  of  different  countries.  They 
really  concern  men  who  were  suffering  at  the  time  of, 
or  shortly  after,  vaccination  from  acute  or  chronic 
infectious  diseases  of  grave  prognosis  (cerebro -spina! 
meningitis,  pneumonia,  broncho -pneumonia,  suppura- 
tive pericarditis,  suppurative  peritonitis  following 
appendicitis,  chronic  myocarditis,  chronic  aortitis, 
nephritis,  and  pleurisy),  which  have  nothing  to  do  with 
vaccination  or  vaccine. 

It  is  therefore  necessary  to  examine  the  individual 
carefully  before  vaccination. 

It  should  be  realised  that  identical  observations  have 
been  made  in  unvaccinated  soldiers,  whose  names  were 
down  on  the  vaccination  lists  and  were  on  the  point  of 
being  vaccinated.  It  not  infrequently  happened  that 
these  men  suddenly  fell  ill  and  died  some  days  before, 


280    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

or  eveir  on  the  day  before,  or  some  hours  before  the  time 
fixed  for  their  vaccination.  The  lesions  found  post 
mortem  were  also  those  of  meningitis,  pulmonary  or 
renal  congestion,  pneumonia,  broncho -pneumonia,  sup- 
purative peritonitis,  acute  or  chronic  nephritis,  etc. 
In  twelve  out  of  one  hundred  cases  the  lesions  were 
insignificant,  in  spite  of  the  severity  and  rapidity  of 
the  symptoms  seen  during  life  in  these  unvaccinated 
subjects.  Fulminating  or  hyperacute  forms  of  cerebro- 
spinal meningitis  or  poliomyelitis  are  often  responsible 
for  these  sudden  deaths,  and  the  diagnosis  is  all  the 
more  difficult  as  macroscopic  lesions  have  not  always 
had  time  to  form. 

These  facts  show  that,  in  presence  of  abnormal  symp- 
toms observed  in  a  vaccinated  subject,  their  cause 
should  always  be  sought  for  in  a  concomitant  morbid 
or  infectious  state  independent  of  vaccination.  Too 
much  care  cannot  be  taken  to  avoid  attributing  to 
vaccination  diseases  which  may  occur  during  the  eight, 
fifteen  or  twenty-one  days  required  for  immunisation. 

The  successful  results  of  preventive  antityphoid 
vaccination  are  well  known.  In  the  French  army  and 
navy,  as  well  as  in  the  English,  Italian  and  Japanese 
armies,  all  the  published  reports  agree  in  showing  the 
remarkable  protection  conferred  by  vaccines.  It  has 
been  the  same  during  the  present  war. 

Antityphoid  vaccination  was  employed  in  the  Eng- 
lish army  in  India  after  the  memorable  experiments  of^ 
A.  E.  Wright.  The  German  army  made  use  of  it  muchj 
later,  in  1904-1907,  at  the  time  of  its  expedition  against 
the  Herreros.  During  the  Russo-Japanese  war  a  cer- 
tain number  of  vaccinations  were  carried  out  in  the 
Russian  sanitary  formations. 

In  the  United  States  antityphoid  vaccination  has  been 
compulsory  in  the  army  and  navy  since  August  28, 191 1. 

In  the  English  army,  before  the  war,  antityphoid 
vaccination,  though  voluntary,  was  used  in  90  per  cent, 
of  the  soldiers  in  India.  A  few  cases  of  paratyphoid 
fever  appeared  there,  but  typhoid  fever  has  considerably 
decreased. 


VACCINATION 

Some  Examples  of  Antityphoid  Vaccination 


281 


Incidence  per  1000 


Non-vac- 
cinated 


Vac- 
cinated 


Mortality  per  1000 


Non-vac- 
cinated 


Vac- 
cinated 


English  Army  in  India  (1906- 
1908)      

English  Army  in  India  (1910)   . 

English  Army  (India,  Egypt, 
Malta,  Crete,  etc.) 

English  Army  in  India  (1911)   . 

English  Army  (1914^an.  1915) 


German  Army  (War  with  the 

Herreros) 

American  Army  (1910)  . 
Japanese  Army    ..... 
French  Army  (Eastern  Morocco) 
French  M6tropole  Army  (1912) 
French  Army,  Algiers  and  Tunis 

(1912)     

French  Army,  Eastern  Morocco 

(1912)     ....... 

French  Army,  Western  Morocco 

(1912)    

French   Army,    Colonial   Army 

Corps     ....... 

French  Army,  Avignon  epidemic 

(1911)     .      .      .     .      ,      .      . 
Paimpol      epidemic      {ciyilian 

population),  (1912) 
Puy  I'Eveque  epidemic  (civilian 

population),  (1912) 
Italian  Army  (1912)  .      .      .      . 
Italian  Army  (1913),  Cyrenaica 
Italian  Army  (1913),  Tripoli      . 


23-33 
13-9 

304 

5-3 

1111 


99 

605 
14-52 
64-97 

2-22 

12-14 
38-23 

168-44 
6-34 

225-61 

41-66 

52-85 
35-3 


3 
4-7 

5-39 
1-7 

1  injec- 
tion : 

83 
cases. 

2  injec- 
tions : 

33 
cases. 

51 
0-48 
1 
0 
0 

0-09 

0 

018 

0 

0 

0 

0 

0-3 
0-29 
0 


3-93 
2-6 

16-9 
0-4 


12-8 
0-46 
1-66 
8-35 
0-30 

1-88 

5-51 
21-13 

0^58 
32-02 

4-58 

7-14 
71 


0-36 
0-6 

8-9 
0-09 


6-47 
0 

0-28 

0 

0 

0 

0 

0  09 

0 

0 

0 

0 
0 
0 
0 


We  have  already  stated  that  triple  vaccination  with 
the  antityphoid  and  antiparatyphoid  A  and  B  vaccine 


282    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

has  been  used  in  the  French  army  since  1910.  This 
triple  vaccination  with  the  Val  de  Grace  vaccine  pro- 
tected the  soldiers  who  were  inoculated  in  Eastern 
Morocco  in  1911  against  the  three  diseases. 

Vaccination  with  T.A.B.  vaccine  was  carried  out  in 
West  Morocco,  where  the  severity  of  typhoid  and  para- 
typhoid infections  is  well  known.  It  was  found  that 
the  mixed  vaccine  had  a  very  powerful  immunising 
action  on  the  three  diseases,  whereas  in  the  civil  popula- 
tion of  Morocco  the  non -vaccinated  continue  to  provide 
numerous  severe  cases.  French  troops  sent  to  Morocco 
at  the  beginning  of  the  war  with  Germany,  who  could 
not  be  vaccinated  owing  to  the  necessities  of  the  war, 
only  managed  to  escape  a  severe  epidemic — ^which  began 
a  fortnight  after  their  arrival — by  means  of  rapid 
vaccination. 

In  like  manner,  German  prisoners  sent  to  Morocco 
would  have  paid  a  heavy  toll  to  typhoid  fever  if  vac- 
cination had  not  cut  short  the  commencement  of 
the  epidemic.  Their  sanitary  condition  since  then  has 
remained  excellent. 

In  Algeria,  inoculation  with  the  triple  vaccine  (T.A.B.) 
has  conferred  a  remarkable  immunity  on  the  troops 
stationed  in  this  country,  where  typhoid  is  so  rife 
(E.  Sergent  and  L.  Negre). 

The  Italian  army  also  employed  in  1912  and  1913 
vaccination  by  the  triple  ether  vaccine,  or  T.A.B.,  in 
Tripoli,  Cyrenaica,  and  in  Italy.  Publications  on  the 
subject  have  been  made  by  the  medical  Inspector- 
General  Ferrero  di  Cavallerleone,  and  an  official  report 
has  been  communicated  by  Professor  Santoliquido, 
Director -General  of  Public  Health  in  Italy. 

The  vaccinations  have  been  performed  in  Italy  with 
the  mixed  T.A.B.  vaccine,  with  three  injections.  The 
vaccinations  were  carried  out  in  two  periods  :  Sep- 
tember 1912-June  1913,  and  June  1913-December 
1913.  In  the  first  period  the  vaccines  of  Pfeiffer-KoUe 
and  Vincent  were  used,  in  the  second  Vincent's  T.A.B. 
vaccine  almost  exclusively,  which  had  been  prepared 
at  the  MUan  Institute  of  Serum  Therapy. 


VACCINATION 


283 


In  the  Libyan  expeditionary  force  the  non-vaccinated 
showed  a  morbidity  of  35-3  per  1000  and  a  mortality 
of  7-1  per  1000. 

In  the  jSrst  period  4682  injections  were  given  with 
the  Pfeiffer-Kolle  vaccine,  and  11,509  with  the  triple 
ether  vaccine.  In  the  second  period  11,703  injections 
were  given. 

A  platinum  loopful  of  a  culture  on  agar  being  taken 
as  unity,  as  German  bacteriologists  advise,  the  doses 
inoculated  were  as  follows — 


1st  injection 

2nd  injection 

3rd  injection 

Vincent's  vaccine     .... 
Heated  Pfeiffer-Kolle  vaccine  . 

0-40 
0-50 

0-90 
1 

1-20 

2 

The  Pfeiffer-Kolle  vaccine  has  thus  been  given  in 
much  larger  doses. 

The  statistics  of  the  morbidity  among  the  vaccinated 
in  the  region  of  North  Africa,  which  is  so  severely 
infected  by  typhoid  fever,  have  shown  the  same  remark- 
able results  as  those  in  the  French  army,  in  the  interior, 
in  Algiers  and  Morocco,  in  striking  contrast  with  the 
morbidity  of  the  non -vaccinated. 


Vaccinated 


Number  of  Cases  of  Typhoid  Fever 


1  injection 
only 


2  injec- 
tions 


3  injec- 
tions 


1.  With    the    triple    ether    vaccine 

(T.A.B.) 

2.  With  the  heated  vaccine  (Pfeiffer- 

Kolle)        


4-4  per 

1000 

10-7  per 

1000 


2-7  per 
1000 

6-9  per 
1000 


0-3  per 
1000 

7-2  per 
1000 


In  the  second  period  of  vaccination  in  the  Italian 
army,  3494  soldiers  were  given  the  T.A.B.  ether  vaccine. 
Their  morbidity  and  mortality  were  as  follows — 

Cases  Deaths 

In  Cyrenaica  .      .      .      .      .      .      0-29  per  1000  0 

In  Tripoli o      0  0 


284    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 


Resultat  de  la  Vaccmation 

au  66fBatai'//on  de  Chasseurs. 

NOMBRE    DES 

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16 

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14 

15 

12 

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8 

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4 

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1200 

1150 

1100 

1050 

1000 

950 

900 

850 

800 

750 

700 

650 

600 

550 

500 

450 

400 

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300 

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200 

150 

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VACCINATION 


285 


Resultats  des  Vaccinations  antityphoyJiquesauMaroc 


286    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

As  the  result  of  these  observations,  Ferrero  pro- 
posed that  vaccination  should  be  made  compulsory  in 
the  Italian  army. 

Antityphoid  vaccination  has  been  made  compulsory 
in  the  French  army  since  March  28,  1911,  on  the  pro- 
posal of  Leon  Labbe.  The  navy  adopted  the  same 
measure  in  November  1914.  Shortly  afterwards  the 
Belgian  War  Minister  took  a  similar  decision. 

Since  the  war  began  simple  or  mixed  vaccination 
has  been  adopted  by  all  the  belligerents. 

It  may  be  asserted  that  in  spite  of  the  occasionally 
very  unsatisfactory  conditions  under  which  it  has  been 
practised  in  France,  in  spite  also  of  the  difficulties  of 
controlling  the  vaccinations  and  the  actual  nature  of 
the  infections  (typhoid  fever,  paratyphoid  fever,  entero- 
coccus  infection,  and  various  other  infections),  preven- 
tive vaccination  has  succeeded  in  saving  the  French 
army  a  very  considerable  number  of  cases  and  deaths. 
Reduced  vaccination,  although  involving  a  correspond- 
ingly reduced  immunity,  has  nevertheless  conferred 
considerable  protection  on  the  corps  among  which  it 
could  be  applied  from  the  first,  e.  g.  5th  Corps  (Javal), 
territory  of  Belfort  (100,000  vaccinated  :  Bousquet), 
4th  army,  5th  army,  77th,  98th,  235th,  243rd,  364th 
divisions,  etc.,  as  well  as  infantry  regiments  in  the 
Belgian  army. 

The  circumstances  of  the  present  war  did  not  at  first 
permit  of  the  imiversal  employment  of  preventive 
vaccination  in  the  army.  But  as  soon  as  this  method 
was  introduced  and  submitted  to  control,  the  epidemic 
curve  in  the  armies  was  found  to  drop  suddenly  and  to 
remain  subsequently  at  a  very  low  level.  Ever  since 
1915  mortality  due  to  typhoid  diseases  has  been  very 
low,  and  the  sanitary  condition  of  the  army  has  for  a 
long  time  been  superior  to  that  in  peace  time.  The 
Russian  brigades  which  have  been  vaccinated  in  France 
with  from  1  to  3  injections  have  also  enjoyed  a 
remarkable  immunity. 

Owing  to  the  nature  of  the  military  operations,  the 
continual  stagnation  of  the  troops  in  the  trenches  and 


VACCINATION 


287 


cantonments,  the  enormous  effectives  engaged,  and  the 
long  duration  of  the  war,  it  may  be  calculated  that 
specific  vaccination  has  saved  the  country  "  an  extra- 
ordinary proportion  of  cases"  and  an  extremely  high 
number  of  deaths. 

Before  the  war  with  Germany  (we  have  no  need  to 


Cas  de  Fievre  typfioide  par  quinzaine  du 
15au310ct     15Nov.    30Nov.    15Dec     3\Dec.   ISJanv.  3Ubm 


■^   Afomure  foia/  c/es  vacc/nsf/ons  c/ans  /e    6*  Corps.  (*) 
•«  A/om6re  tota/c/es  cas  c/e  fievre  tjphoic/e  c/ansk  5*  Lorps. 
■••      45*  /f.^(/'ar////ene  c/e  campagne 
•KJ        2*  R^J'art///ene  /ourt/e 


allude  to  the  now  classical  example  of  the  Avignon 
epidemic  in  1911,  when  among  687  non-vaccinated 
soldiers  there  were  155  cases  of  typhoid  fever  with 
22  deaths,  whereas  among  1366  completely  vaccinated 
there  was  not  a  single  case  of  this  disease),  a  young 
doctor  who  had  been  vaccinated  during  the  incubation 
stage  had  a  suspicious   febrile  gastric  attack.     Three 


288    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

rrlild  cases  also  appeared  after  the  first  or  second  injec- 
tion in  men  who  were  in  the  incubation  stage,  and 
consequently  already  infected  at  the  time  that  the 
injection  was  made. 

Epidemio  of  Avignon  (1912) 

Present  numbers  of  the  garrison 2053 

Number  of  vaccinated  soldiers — 

1.  Before  the  epidemic 525 

2.  During  the  epidemic 841 

Total  number  vaccinated  (ether  vaccine)     .   1366 


Deaths  from  Typhoid  Fever 


Cases 

Deaths 

Number 

Incidence  per 
1000 

Number 

Incidence 
par  1000 

Non-vaccinated   687 
Vaccinated         1366 

155 
0 

225-61 
0 

22 
0 

32-02 
0 

The  following  year  the  complete  garrison  of  Avignon, 
containing  2420  men,  was  vaccinated,  and  there  was 
no  case  of  typhoid  fever.  Among  the  soldiers  in  this 
town,  from  1892  to  1912  inclusive,  there  had  been  1263 
cases  of  typhoid  fever  and  118  deaths.  In  1913  all 
these  figures  were  reduced  to  zero. 

Similarly  conclusive  observations  were  made  on  the 
occasion  of  the  military  epidemics  of  Larissa  (Greek 
army,  1912),  Marseilles,  Issoudun,  Tours,  etc. 

At  Tours  a  severe  epidemic  of  typhoid  fever  occurred 
in  January-February,  1914.  A  single  company  of  the 
66th  infantry  regiment  had  37  cases  out  of  180  men. 
The  company  was  vaccinated  at  once  and  the  epidemic 
ceased,  but  it  appeared  again  in  the  other  companies. 
Influenza,  scarlatina,  mumps,  and  cerebro -spinal 
meningitis  were  prevalent  at  the  same  time.  Never- 
theless, the  whole  regiment  was  vaccinated,  and  the 
epidemic  was  thereby  brought  to  an  end.  This  epidemic 


VACCINATION 


289 


was  almost  comparable  in  severity  to  that  of  Avignon. 
The  figures  are  as  follows — 


Tours  Epidemic 

Cases 

Deaths 

^-^-       P-PO^- 

Number 

Proportion 
per  1000 

Non- vaccinated       488 
Vaccinated              1646 

96 
0 

199 
0 

21 

0 

43-40 
0 

The  vaccinations  carried  out  in  the  civil  population 
at  Avignon  (400  inhabitants),  Puy  I'Eveque  (Lot), 
Paimpol,  etc.,  on  the  occasion  of  severe  epidemics  gave 
rise  to  the  same  conclusive  observations.  In  a  certain 
number  of  places  or  towns,  e.  g.  Grans  (Bouches-du- 
Rhone),  Rouffignac  (Dordogne),  Alais,  Egletons  (Correze), 
Sermaizes  (Loiret),  Ymouville  (Eure-et-Loir),  Andilly 
andMargency  (Seine-et-Oise),  Donges  (Loire -Inferieure), 
etc.,  the  protection  acquired  by  the  vaccinated  proved 
to  be  remarkably  complete. 

We  may  quote  as  an  example  the  cases  of  the 
epidemic  observed  at  Largeau  (Loiret),  from  June  to 
September  1913,  by  Dr.  Grancher.  This  epidemic  was 
due  to  milk,  and  fourteen  families  making"  use  of  the 
infected  milk  were  attacked.  Dr.  Grancher  vaccinated 
the  members  of  seven  families  with  Vincent's  vaccine, 
and  the  other  seven  refused.  The  result  was  that- 
typhoid  fever  continued  for  three  months  by  means  of 
contagion  from  person  to  person  in  these  families,  among 
whom  it  caused  fearful  ravages,  all — or  almost  all — their 
members  being  attacked  in  succession.  In  one  of  these 
families  seven  persons  out  of  eight  had  typhoid  fever 
in  succession.  The  grandmother  alone,  aged  seventy- 
two,  escaped.  On  the  other  hand,  the  inhabitants 
(eighty  persons,  including  forty  women  and  eight 
children)  who  had  been  vaccinated  even  partially  were 
entirely  protected  against  infection. 

At  Sivas  (Turkey  in  Asia),  Seville  (Prof.  Juan  Peset), 
where  624  persons  were  vaccinated,  Noguer  (Spain), 


290    TYPHOID  FEVER  AND  PARATYPHOID  FEVERS 

the  Belgian  Congo  (Dr.  de  Ruddere,  Dr.  Polidore  and 
Dr.  Valche),  Medellin  (Columbia),  Connixheim  (Bel- 
gium), etc.,  similar  examples  of  immunity  have  been 
observed. 

A  very  important  fact  is  that  when  the  inoculations 
are  rapidly  carried  out  on  all  the  persons  liable  to 
infection,  they  exercise  an  arresting  action  upon  the 
epidemic,  which  dies  down  rapidl}^  when  the  second  oi? 
third  injection  of  vaccine  has  been  given. 

The  statistics  published  by  Leishman  for  the  English 
army  in  India  and  the  other  colonies,  by  Russell 
for  the  United  States  army,  etc.,  testify,  with  the 
authorities  already  quoted,  that  specific  vaccination 
is  the  most  powerful  j)rop>Tiylactic  measure  ivhich  we 
possess  against  typhoid  fever.  From  this  point  of 
view  it  may  be  compared  with  vaccination  against 
smallpox. 

Before  concluding,  it  seems  imperative  to  insist  on 
the  absolute  necessity  of  applying  vaccination  rigor- 
ously to  obtain  all  the  effects  which  one  is  entitled  to 
expect  from  it.  The  difficulties  in  practice  due  to  the 
state  of  war  are  obviously  great. 

Furthermore,  the  frequency  with  which  the  soldiers 
to  be  vaccinated  are  lea\ing  or  changing  their  billets 
explains  the  fact  that  vaccination  in  war  time  may  be 
carried  out  incompletely,  or  improperly  registered  or 
controlled.  Errors  are  likely  to  be  all  the  more  numer- 
ous as  enormous  bodies  of  men  are  being  dealt  with. 
We  cannot,  therefore,  too  frequently  repeat  the  advice 
to  conform  minutely  to  the  practical  rules  for  vaccina- 
tion, to  enter  each  of  the  injections  carefully  and  with 
rigorous  exactitude  on  the  vaccination  card,  and  to 
keep  a  record  of  it  in  a  special  register. 

During  the  arrival  in  large  numbers  of  men  to  be 
vaccinated,  either  in  barracks  or  at  the  Front,  numerous 
causes  of  error  may  arise,  such  as  entering  men  absent 
or  postponed  on  the  list  of  those  actually  vaccinated, 
hasty  signing  of  certificates,  frauds  due  to  the  soldiers, 
any  one  of  whom  for  a  consideration  will  take  the  place 
of  another  and  reply  when  his  name  is  called  out,  while 


VACCINATION  291 

others  imitate  the  Medical  Officer's  signature  and  repro- 
duce it  in  their  books,  or  obtain  an  inaccurate  certificate 
from  an  obhging  orderly.  The  attention  of  Medical 
Officers  who  perform  the  vaccination  should  be  called 
to  these  facts,  and  to  their  frequent  results.  Inquiry, 
in  fact,  has  proved  the  great  frequency  of  mock 
vaccinations  in  war  time. 

It  will  be  well  to  remember  that  many  soldiers  con- 
fuse vaccination  against  smallpox  with  antityphoid 
vaccination — Wright  formerly  drew  attention  to  the 
same  occurrence  in  the  English  army — and  a  large 
number  still  appeal  to  a  vaccination  which  does  not 
exist  to  escape  injections. 

Medical  Officers  who  are  entrusted  with  the  carrying 
out  of  vaccination  should  provide  themselves  with 
reliable  assistants,  and  take  the  greatest  care  not  only 
in  the  technique  of  the  injections  and  previous  examina- 
tions of  the  subjects  to  be  vaccinated,  but  also  in  every- 
thing concerning  the  verification  of  the  states  of 
vaccination,  the  exact  control  of  the  injections  per- 
formed, with  their  dates  and  doses,  the  registration  of 
the  absent,  sick,  and  those  on  leave  ;  for  any  neglect  or 
forgetfulness  may  result  in  attributing  an  undeserved 
failure  to  this  successful  method,  and,  what  is  more 
serious,  in  exposing  soldiers  to  a  dangerous  infectious 
disease,  the  prognosis  of  which  is  often  fatal. 


SECTION  II 

DYSENTERY 

ASIATIC  CHOLERA  AND 

EXANTHEMATIC  TYPHUS 


DYSENTERIES 


PART  /.—CLINICAL    SURVEY 

CHAPTER  I 

SYMPTOMATOLOGY 

The  term  dysentery  serves  to  denote  a  symptom  com- 
plex which  indicates  an  ulcerative  colitis,  acute  or 
chronic,  which  may  be  due  to  various  pathogenic  agents, 
such  as  dysentery  bacilli,  amoebae,  etc. 

These  affections,  etiologically  quite  distinct,  are  con- 
tagious. They  present  some  common  symptoms,  and 
each  of  them  possesses  its  special  symptoms. 

The  dysenteric  syndrome  comprises  three  essential 
symptoms  common  to  all  dysenteries  : 

1.  Abdominal  pains. 

2.  Tenesmus. 

3.  Stools  presenting  a  characteristic  appearance. 

1.  Abdominal  Pains. — The  abdominal  pains  are  spon- 
taneous or  provoked.  The  spontaneous  pains  manifest 
themselves  as  colics,  sometimes  generalised  throughout 
the  abdomen,  sometimes  localised  in  the  mnbilical 
region  or  the  left  iliac  fossa,  and  by  extremely  severe 
griping  pains  (tormina),  which  follow  the  entire  course 
of  the  colon  as  far  as  the  rectum.  In  slight  cases  the 
griping  pains  are  transient,  occurring  at  the  moment 
of  alvine  evacuation,  diminishing  immediately  after 
evacuation  and  then  disappearing.  In  more  serious 
cases  they  are  much  more  frequent,  and  may  occur  in  the 
absence  of  any  evacuation.  Pressure  exerted  on  the 
large  intestine  causes  a  more  or  less  acute  pain,  especially 
in  the  region  of  the  left  iliac  fossa.  It  is  often  possible, 
by  the  localisation  of  the  pains  thus  produced,  to  map 

29.5 


•^96    DYSENTERY,  CHOLERA,  AND  TYPHUS 

out  the  extent  of  the  intestinal  surface  affected.  Ab- 
dominal pains  may  be  absent  in  cases  which  are  from 
the  first  very  serious  (Dutroulau).  They  become 
progressively  less  severe,  having  at  first  been  rather 
violent,  to  disappear  completely  when  gangrenous 
lesions  occur. 

2.  Tenesmus. — ^The  patient  is  aware,  in  the  slighter 
cases,  of  a  feeling  of  weight,  of  a  foreign  body  in  the 
rectum  ;  but  most  frequently  there  is  a  painful  feeling 
of  tension  and  constriction  in  the  region  of  the  anus, 
with  an  incessant  call  to  pass  stools.  Sometimes  a 
number  of  false  calls  are  followed  by  fruitless  efforts 
(tenesmus) ;  sometimes  the  straining  results  in  the 
expulsion  of  a  very  small  quantity  of  excrement  (barely 
a  teaspoonful).  Each  attempt  causes  extremely  violent 
pains  (smarting,  burning,  tearing  sensations),  recurrences 
of  these  being  provoked  by  the  slightest  incidents,  such 
as  coughing,  sneezing,  deglutition,  etc. 

The  sum  of  these  sensitive  disorders,  localised  in 
the  terminal  portion  of  the  rectiun,  constitutes  rectal 
tenesmus,  which,  in  a  number  of  cases,  is  accompanied 
by  analogous  symptoms  affecting  the  bladder  (vesical 
tenes7nus). 

Rectal  tenesmus  is  frequently  complicated  by  paralysis 
of  the  sphincter  and  the  levator  ani  (Trousseau,  Colin) ; 
repeated  efforts  to  defaecate  may  cause  prolapse  of  the 
rectum,  an  accident  common  in  children. 

The  intensity  of  the  tenesmus  varies  greatly  in 
different  patients.  In  hot  countries  tenesmus  is  said 
to  be  often  absent,  or  transient,  and  is  confined  to  a 
mere  sensation  of  smarting  ;  it  is  said  to  be  infrequent 
in  India.  According  to  Sir  Patrick  Manson,  the  nearer 
the  lesion  to  the  rectum,  the  more  severe  the  tenesmus  ; 
the  nearer  to  the  caecum,  the  more  violent  the  colic. 
These  two  symptoms,  in  addition  to  the  presence  of 
painful  spots,  constitute,  in  the  majority  of  cases,  a 
reliable  guide  to  the  localisation  of  the  lesions  and  to  an 
estimate  of  their  extent. 


SYMPTOMATOLOGY  297 

3.  Dysenteric  Stools.  —  Constipation  being  the  general 
rule  in  confirmed  dysentery,  the  true  dysenteric  stools 
contain  little  or  no  faecal  matter.  Their  varying  aspect 
has  given  rise  to  numerous  comparisons.  Sometimes 
they  consist  of  transparent  and  whitish  mucus,  diffluent, 
of  a  membranous  aspect,  twisted,  or  wound  into 
viscous  masses,  and  have  been  compared  to  scrapings  of 
the  bowels  (Jaccoud) ;  sometimes  the  mucus  is  flaky, 
or  in  rice-like  grains,  or  in  punctiform  debris,  or  the 
matter  excreted  has  the  appearance  of  frogs^  spawn  or 
the  white  of  raw  eggs.  The  stools  are  usually  blood- 
stained, owing  to  the  extension  of  the  ulcerative  process 
to  the  vessels  of  the  intestinal  wall.  In  these  cases  the 
blood  merely  streaks  the  mucus,  or  appears  on  its  surface 
in  the  form  of  patches  of  varying  extent,  or  again,  it  is 
so  intimately  mixed  with  the  mucus  that  the  stool 
resembles  the  rusty  sputum  of  the  pneumonic  patient. 

Sometimes  the  mucus,  scanty  and  sanguinolent, 
floats  in  a  serous  liquid,  of  a  pink  or  reddish  colour; 
it  has  been  described  as  resembling  water  in  which 
raw  meat  has  been  washed.  In  other  cases  the 
haemorrhagic  stools  consist  of  almost  pure  blood,  red 
and  fluid  or  black  and  mingled  with  clots.  Lastly, 
they  may  be  gangrenous.  Shapeless  shreds  of  sphace- 
lated mucus  float  in  a  serous  liquid',  reddish,  brown, 
or  black,  with  a  horrible  smell. 

Kelsch  has  very  justly  remarked  that  the  alvine 
dejecta  reflect,  by  their  aspect  and  their  nature,  the 
degree  and  the  nature  of  the  intestinal  lesions. 

The  number  of  stools  is  always  considerable  in 
dysentery  :  10,  30,  50,  and  even  more  in  the  twenty- 
four  hours  ;  160  to  180  in  a  case  of  Trousseau's  ;  200 
in  twelve  hours  in  a  case  of  Zimmerman's. 

The  stools  are  more  frequent  at  night  than  in  the  day. 
The  matter  expelled  each  time  is  by  no  means  abundant, 
especially  at  the  outset ;  it  becomes  more  copious  as 
the  malady  develops.  Barely  a  hundred  grammes 
(about  3|  oz.)  in  benign  cases,  it  may  amount  to  several 
litres  in  cases  of  bilious  dysentery. 


298    DYSENTERY,  CHOLERA,  AND  TYPHUS 

The  mucus  has  a  stale  or  putrid  odour,  and  its 
reaction  is  alkaline. 

Such  is  the  dysenteric  syndrome  common  to  all 
dysenteries,  whatever  their  infectious  agent.  Many 
of  these  exist,  and  they  can  be  determined  only  by 
investigation  in  the  laboratory. 

We  may  distinguish,  in  the  first  place,  among  the 
acute  forms  of  dysentery,  two  forms  which  are  clearly 
defined,  and  which  are  by  f^r  the  most  frequent : 

1.  Bacillary  dysentery. 

2.  Amoebic  dysentery. 

In  the  second  place,  we  find  dysenteric  conditions 
due  to  various  other  etiological  agents  :  spirilla,  cocco- 
bacilli.  Bacillus  pyocyaneus,  Balantidium  coli.  Schisto- 
soma mansoni,  Chilodon  dentatus,  etc.,  which  have  all  to 
be  investigated. 

We  shall  here  consider  bacillary  and  amoebic 
dysentery. 

I.  Bacillary  Dysentery 

The  clinical  development  of  bacillary  dysentery  com- 
prises a  period  of  incubation,  a  period  of  onset,  an  acute 
dysenteric  period,  and  a  terminal  period. 

1.  Period  of  Incubation. — ^This  period  is  generally  of 
brief  duration :  forty-eight  hours  (Strong  and  Musgrave), 
or  two  to  three  days  (Lentz).  In  experimental  in- 
fections of  man  effected  by  Strong  and  Musgrave  and 
others,  the  first  symptoms  manifested  themselves 
twenty-four  hours  after  the  ingestion  of  the  culture 
of  dysentery  bacilli. 

2.  Period  of  Onset. — Very  rarely  a  prodromal  period 
is  observed,  characterised  by  mucous  or  bilious 
diarrhoea.  In  reality  it  constitutes  the  first  stage  of 
the  infection.  This  premonitory  diarrhoea,  when  it 
exists,  lasts  barely  twenty-four  to  thirty-six  hours. 

As  a  general  rule,  dysentery  makes  its  appearance 
suddenly,  without  prodromes,  and  in  a  few  hours  the 
acute  period  is  established. 


SYMPTOMATOLOGY  299 

3,  Acute  Dysenteric  Period. — In  the  slightest  cases 
the  affection  amounts  to  a  diarrhoea  of  ordinary  appear- 
ance. The  stools  are  not  numerous  and  contain  only 
traces  of  mucus.  In  this  category  are  contained  a 
certain  number  of  cases  of  summer  diarrhoea,  with 
abdominal  and  rectal  pains  which  are  scarcely  notice- 
able, a  fair  number  of  cases  of  infantile  diarrhoea,  and 
also  certain  cases  of  "  trench  diarrhoea." 

Most  usually  the  patient  experiences,  at  the  outset, 
vague  abdominal  pains,  followed  by  more  violent  colics, 
with  a  sensation  of  fulness  in  the  region  of  the  rectum, 
which  brings  on  a  more  and  more  imperative  call  to 
stool.  Then  the  dysenteric  syndrome  sets  in  in  all  its 
intensity  :  colics,  straining,  tenesmus  and  character- 
istic stools.  At  this  stage  the  patient  may  suffer  from 
nausea,  hiccough  and  mucous  or  bilious  vomiting.  The 
abdomen  is  retracted  and  painful ;  the  urine,  which  is 
diminished,  often  contains  albumin  ;  the  tongue  is  dry  ; 
the  liver  congested,  and  increased  in  volume,  and  painful 
under  pressure,  especially  in  the  region  of  the  gall- 
bladder. 

Fever  may  be  regarded  as  exceptional  during  dysen- 
tery. When  it  is  present  it  rarely  exceeds  102-2°  F., 
and  shows  itself  only  during  the  first  three  or  four  days 
of  the  disease. 

The  malady  may  develop  with  a  grave  prognosis,  and 
may  even  terminate  in  death,  without  a  considerable 
rise  of  temperature  ;  hypothermia  may  be  observed  in 
the  very  toxic  forms. 

The  pulse  is  generally  frequent,  small,  and  often 
irregular.  The  face  is  pale  and  dejected;  emaciation 
is  often  rapid  and  very  pronounced. 

4.  Terminal  Period. — In  favourable  cases,  after  an 
average  of  three  to  ten  days,  the  colic  and  tenesmus 
become  less  severe.  The  stools,  less  frequent,  lose 
their  dysenteric  character  and  become  faecal.  Occasion- 
ally there  is  an  intestinal  flushing,  of  a  bilious  or  sero- 
bilious  nature,  which  continues  for  some  days.     Then 


300      DYSENTERY,  CHOLERA,  AND  TYPHUS 

the  stools  gradually  resume  their  normal  appearance 
and  consistency.  At  this  stage  constipation  may  be 
met  with,  and  after  this  a  relapse  may  occur. 

Sometimes,  at  the  beginning  of  the  convalescent 
period,  increased  sweating  and  an  increase  in  the 
amount  of  urine  is  observed ;  these  may  even  assume 
the  characters  of  a  true  crisis. 

The  patient's  strength  recuperates  slowly ;  some- 
times the  convalescence  is  longer  than  the  malady. 

Bacillary  dysentery  is  benign,  of  medium  severity, 
or  severe.  In  certain  cases  the  dysentery  is  serious 
from  the  outset ;  in  others  grave  complications  may 
appear  during  the  course  of  a  benign  dysentery,  which 
modify  its  development.     It  ends  in  recovery  or  death. 

Clinical  Forms  of  Bacillary  Dysentery 

1.  The  Light  Form. — ^Dysentery  may  often  present 
the  appearance  of  an  ordinary  diarrhoea.  The  patient 
suffers  from  a  certain  amount  of  nausea,  the  tongue 
is  clammy  and  resembles  that  seen  in  indigestion, 
and  the  abdominal  pains  are  not  very  pronounced  ; 
the  stools  are  not  very  frequent — 4  to  6  per  diem — and 
contain  only  traces  of  mucus,  which  may  easily  pajss 
unperceived.  The  affection  lasts  a  few  days  only,  and 
its  dysenteric  nature  is  most  frequently  unrecognised. 

2.  Bilious  Form. — ^The  malady  commences  with  a 
violent  gastric  disturbance,  with  congestion  of  the  liver, 
vomiting,  and  very  abundant  bilious  diarrhoea.  After 
the  lapse  of  a  few  days  the  stools,  turgid  and  frothy, 
contain  slimy  mucus  coloured  with  bile.  Jaundice  is 
generally  observed. 

3.  Fulminating  Form. — ^The  onset  is  sudden,  in  the 
middle  of  the  night,  with  more  or  less  violent  rigors, 
vomiting,  severe  headache,  and  a  rise  of  temperature  to 
102°  or  104°.  At  the  same  time  the  stools  assimie  the 
dysenteric  character.  In  the  space  of  two  or  three  days 
to  a  week  (approximately),  the  fever  persisting  to  the 


SYMPTOMATOLOGY  301 

end,  collapse  sets  in  with  hypothermia,  and  the  patient 
expires.  In  certain  cases  death  may  occur  even 
before  dysenteric  stools  are  passed,  so  virulent  is  the 
intoxication  (Manson). 

4.  Ulcerative  Form.  —  The  stools,  after  a  benign 
commencement,  become  fetid,  and  contain  not  only 
blood,  but  also  a  more  or  less  voluminous  gangrenous 
debris,  of  a  greyish  hue,  with  a  putrid  odour. 

This  denotes  the  existence  of  deep  ulcerations,  which 
are  slow  to  cicatrise,  and  tend  to_  set  up  a  relapsing 
dysentery. 

5.  Gangrenous  Form. — ^This  is  observed  in  tropical 
regions  ;  very  rarely  in  temperate  countries.  From 
the  outset  it  is  a  very  serious  malady.  The  stools 
are  incessant ;  the  pains,  which  are  excruciating,  spread 
in  all  directions,  not  only  through  the  abdomen,  but 
also  along  the  course  of  the  sciatic  nerve  and  in  the 
region  of  the  testicles  (Le  Dantec).  Tenesmus  is  very 
severe  ;  the  temperature  may  be  febrile,  the  face  pale, 
shrunken  and  altered,  the  eyes  sunken.  The  general 
condition  is  bad,  the  voice  feeble,  the  pulse  small 
and  thread-like  and  slower  than  the  normal.  There 
is  incessant  vomiting  and  a  pathognomic  hiccough 
sets  in. 

The  stools,  at  first  blood-stained,  shortly  assume  the 
gangrenous  type  described  above.  At  the  same  time 
the  pains  abate,  even  disappearing  completely,  and  the 
patient  feels  better.  This  improvement  is  deceptive, 
for  the  vital  powers  are  failing  ;  the  heart  grows  weaker 
and  the  pulse  becomes  barely  perceptible.  The  skin 
grows  cold  and  cyanosed,  and  is  covered  with  a  clammy 
perspiration.  The  mind  remains  clear,  though  a  little 
less  active,  and  the  patient  slowly  expires  without  a 
death  struggle,  without  suffering,  unless  he  is  suddenly 
carried  off  by  a  syncopal  attack.  Death  is  the  usual 
termination  of  gangrenous  dysentery.  However,  in 
rare  instances,  recoveries  have  been  reported  (Dutrou- 
lau,  Laveran,  Berenger-Feraud,  etc.). 


302  DYSENTERY,  CHOLERA,  AND  TYPHUS 

6.  Choleraic  Form.  —  In  Cochin-China  a  form  of 
dysentery  is  occasionally  observed  with  vomiting, 
cyanosis,  collapse,  algidity,  muscular  cramps,  suppres- 
sion of  urine,  and  a  "  broken"  voice,  these  giving  the 
patient  an  aspect  comparable  to  that  of  cholera. 
During  the  present  war  P.  Remlinger  and  J.  Dumas 
•have  observed  in  4  per  cent,  of  cases — in  benign 
cases  as  well  as  in  those  which  were  serious  from  the 
first — at  the  outset,  or  when  the  malady  is  estab- 
lished, or  during  convalescence,  an  acute'  supra-renal 
syndrome  recalling  cholera.  In  a  few  hours  the  patient 
literally  "melts  away."  He  appears  fleshless,  skeleton- 
like, the  eyes  sunken,  the  nose  sharp,  the  abdomen 
hollowed  like  a  boat.  There  is  cyanosis,  the  tempera- 
ture falls  ;  the  pulse,  frequent  and  compressible,  is  im- 
perceptible or  nearly  so.  The  heart  sounds  are  remote 
and  muffled,  often  of  an  embryocardiac  type.  The 
tongue  is  dry ;  the  patient  has  an  inextinguishable 
thirst,  with  hiccough >  nausea,  vomiting  ;  his  voice  is 
broken ;  he  has  cramps ;  and  there  is  abundant  and 
very  liquid  diarrhoea.  The  evacuations  are  sometimes 
involuntary.  There  is  oliguria,  or  even  anuria.  The 
patient  becomes  prostrated  and  plunged  into  a  condi- 
tion of  semi-somnolence.  Death  follows  rapidly.  The 
above-named  authors  have  found  histological  lesions 
in  the  supra-renal  capsules,  which  are  two  to  three 
times  larger  than  usual. 

7.  Tsnphoidal  Form. — This  form  is  characterised  by 
high  temperature,  dryness  of  the  tongue,  abdominal 
meteorism,  stupor,  delirium,  ataxo -adynamic  pheno- 
mena, and  in  children  by  convulsions.  The  stools, 
dysenteric  during  the  first  week,  afterwards  become 
diarrhoeal.  Although  these  forms  occur  most  frequently 
apart  from  any  association  with  typhus  or  typhoid 
fever,  it  must  not  be  forgotten  that  in  the  course  of  all 
wars,  and  notably  during  the  present  war,  cases  of 
mixed  infections  have  been  recorded,  such  as  those  of 
typhoid  fever  and  dysentery  (Remlinger). 


SYMPTOMATOLOGY  303 

8.  Haemorrhagic  Form. — This  form  of  dysentery,  which 
is  haemorrhagic  from  the  commencement,  is  rare. 
Le  Dantec  has  observed  one  case,  which  was  quickly 
fatal.  Most  frequently  the  haemorrhage  is  intestinal ; 
it  has  the  same  pathogeny  as  the  haemorrhage  of 
typhoid  fever.  It  may  occur  at  any  stage  of  the  dis- 
ease, and  is  usually  accompanied  by  typhoid-like 
symptoms.  A  sudden  collapse  may  result,  even  in 
cases  otherwise  benign.  Kelsch  and  Kiener  include 
under  this  form  all  cases  with  marked  or  serious 
haemorrhage,  whether  of  the  intestines,  the  mucous 
membranes,  the  cellular  tissue,  or  the  skin. 

9.  Long-continuing  or  Relapsing  Form. — Recovery  after 
severe  or  serious  cases  of  dysentery  may  be  appar- 
ent only.  Often  the  stools  become  irregular,  while 
digestion  is  difficult  and  painful,  accompanied  by  colic 
and  slight  diarrhoea  of  variable  aspect  (mucous,  bilious, 
serous,  sanguinolent,  sometimes  fetid).  The  abdomen 
remains  sensitive,  the  patient  slowly  becomes  cachectic, 
and  dies  at  the  end  of  a  few  weeks,  or  else,  after  a  de- 
parture from  strict  diet,  or  after  a  chill,  or  fatigue,  an 
actual  relapse  occurs,  which  develops  as  in  the  original 
attack.  Thus  there  may  be  alternate  periods  of 
quiescence  and  recrudescence,  which  may  continue  for 
a  varying  space  of  time.  Recovery  may  be  established 
after  several  months,  but  death  is  only  too  often  the 
outcome  either  of  a  serious  relapse  or  of  a  progressive 
cachexia. 

10.  Chronic  Form. — Bacillary  dysentery  may  some- 
times, though  much  less  frequently  than  amoebic 
dysentery,  give  rise  to  a  chronic  condition  (H.  Vincent). 
The  patient,  after  an  acute  period  of  varying  duration, 
continues,  for  several  months,  a  year,  or  longer,  to  pass 
fluid  and  lienteric  stools. 

Their  number  is  3,  4  or  5  per  diem,  with  more  marked 
inflammatory  attacks,  straining,  and  tenesmus  provoked 
by  errors  of  diet,  chills  or  fatigue.  This  form  of 
dysentery  is  often  unrecognised,  above  all  when  the 


304    DYSENTERY,  CHOLERA,  AND  TYPHUS 

initial  period  of  mucous  and  sanguinolent  stools  has 
been  very  short  or  has  passed  unperceived.  The 
patient  grows  steadily  thinner,  his  muscles  become 
wasted,  and  he  falls  into  a  condition  of  marasmus, 
often  confounded  with  intestinal  tuberculosis. 

Complications 

In  the  course  of  bacillary  dysentery  intestinal 
hcemorrhage  may  be  met  with;  this  may  be  primary 
or  secondary,  as  in  typhoid  fever.  Peritonitis  is  not 
exceptional,  with  or  without  intestinal  perforation. 
The  most  usual  position  of  the  latter  is  said  to  be  the 
rectum,  and  after  that  the  sigmoid  flexure. 

Nervous  disorders  (peripheral  neuritis,  paraplegia, 
monoplegia,  general  paralysis  more  rarely)  are  fairly 
frequent  (Zimmermann,  Trousseau,  Bouillaud,  Ridoux, 
Moutard-Martin,  Gubler,  Delioux,  Pugibet). 

Arthropathies  :  these  may  occur  at  any  stage  of 
acute  dysentery.  Sometimes  they  amount  merely  to 
polyarticular  manifestations  of  brief  duration  ;  some- 
times to  mono-  or  bi-articular  localisations  of  a  more 
persistent  character.  Dysenteric  arthritis  sometimes 
assumes  the  character  of  infectious  pseudo-rheumatism 
(Brault,  Boudet) ;  it  is  most  frequently  characterised 
by  a  painful  swelling  of  the  joints  with  or  without 
effusion. 

Combay  has  recorded  a  case  of  thrombosis  of  the  left 
iliac  artery  with  gangrene  of  the  corresponding  limb. 
Cicatricial  strictures  of  the  intestine,  especially  in  the 
region  of  the  rectum,  are  comparatively  frequent  com- 
plications. Invagination,  intestinal  occlusion,  and 
internal  strangulation  have  also  been  reported. 
Remlinger  has  noted  certain  rare  complications  : 
epididymitis,  and  general  dropsy  without  albuminuria. 
Acute  nephritis  is  fairly  common. 


SYMPTOMATOLOGY  305 

II.  Amcebic  Dysentery 

Amoebic  dysentery  presents  the  same  essential 
symptoms  as  bacillary  dysentery.  Long  regarded  as 
peculiar  to  tropical  or  semi-tropical  regions,  it  has 
been  observed  in  all  parts  of  Europe,  and  during  the 
present  war  numerous  cases  have  been  observed  in 
France  (Ravaut  and  Krolunitsky,  Job,  Richet  junior, 
Rist,  Rathery,  Rives  and  Huet,  Lian  and  Lyon-Caen, 
Orticcni  and  Ameuille,  Job  and  Hirtzmann,  etc.).  It 
is  characterised  by  its  tendency  to  relapse  or  assume 
the  chronic  form,  by  its  irregular  development,  con- 
sisting of  periods  of  quiescence  and  exacerbation,  and, 
lastly,  by  the  frequency  of  hepatic  complications 
(simple  congestion  or  abscess  of  the  liver). 

It  may  commence  suddenly,  develop  in  an  acute 
form,  and  end  in  death  or  recovery  in  a  comparatively 
short  time.     This  is  the  less  usual  form. 

The  commencement  is  almost  always  insidious,  often 
marked  only  by  a  simple  diarrhoea,  painless  and  hardly 
inconvenient.  The  dysenteric  syndrome  makes  its  ap- 
pearance in  the  course  of  a  few  days  and  the  patient 
appears  to  improve.  But  as  a  rule  this  improvement 
is  only  apparent.  After  a  period  of  varying  duration  a 
series  of  relapses  occurs,  and  the  malady  becomes  chronic. 

Abdominal  pains  along  the  course  of  the  large  in- 
testine are  constant.  They  may  be  elicited  by  pressure, 
especially  in  the  region  of  the  ulcerations — namely,  the 
caecum,  the  hepatic  flexure,  and  the  sigmoid  flexure-. 
When  they  are  localised  in  the  latter  portion  of  the  large 
intestine  the  ulcerations  are  particularly  painful, 
provoking  rectal  and  vesical  tenesmus,  and  frequently 
recurring  efforts  which  are  not  always  followed  by 
evacuation. 

Alternatively,  the  patient  passes  diarrhoeal  stools, 
sometimes  absolutely  liquid,  sometimes  soft  and 
doughy,  and  then  frequent  dysenteric  stools,  especi- 
ally during  the  night,  with  tenesmus  and  colic.  The 
mucus  evacuated  is  whitish  or  greyish,  more  or  less 


306    DYSENTERY,  CHOLERA,  AND  TYPHUS 

streaked  with  blood  on  the  surface.  In  it  we  find  red 
corpuscles  and  leucocytes,  many  of  which  are  eosino- 
phile  (Billet).  This  latter  fact  has  not,  however,  always 
been  confirmed.  The  odour  of  the  mucous  discharges 
is  sometimes  stale,  sometimes  fetid  ;  their  reaction  is 
alkaline  (H.  Vincent).  Jaundice  is  common.  Diges- 
tion is  painful  and  difficult,  and  there  may  be  frequent 
vomiting.  The  general  condition  of  the  patient  grows 
worse  and  worse,  his  emaciation  more  and  more  per- 
ceptible, although  the  appetite  may  be  fairly  well 
maintained.  If  complications  are  of  some  duration, 
the  patient  becomes  cachectic.  His  skin  is  dry,  wrinkled, 
and  assumes  a  bronzed  and' earthy  tint;  there  is  no 
perspiration,  the  urine  is  scanty,  and  its  emission  is 
sometimes  painful.  The  temperature  may  sink  below 
the  normal,  as  low  as  93-2°  in  the  axilla.  The  patient 
is  like  a  living  skeleton,  and  he  dies  of  inanition,  unless 
he  is  carried  off  by  an  acute  crisis,  an  attack  of  intestinal 
gangrene,  tuberculosis,  or  a  secondary  infection. 

Chronic  dysentery  is  of  extremely  variable  duration, 
lasting  from  a  few  months  to  many  years. i  It  may 
ultimately  end  in  complete  recovery,  without  sequelae. 
Very  frequently  relapses  are  observed  after  a  few  days, 
a  few  months,  or  even  a  year  (H.  Vincent).  Chronic 
and  long-continuing  forms  are  particularly  refractory, 
often  leaving  behind  them  severe  dyspepsia,  extreme 
weakness,  emaciation,  and  even  lesions  (destruction 
of  glands,  thickening  of  the  intestinal  walls,  cicatrices, 
adhesions,  strictures,  etc.),  so  that  the  health  of  the 
patient  afflicted  with  them  is  usually  jeopardised. 

Complications 

The  fact  that  the  development  of  amoebic  dysentery 
is  generally  prolonged  explains  the  multiplicity  and 
the  nature  of  the  complications  which  have  been 
observed  in  the  course  of  this  disease. 

^  Cases  have  recently  been  reported  where  the  infection  had  lasted 
for  20,  26,  and  30  years.  — Ed. 


SYMPTOMATOLOGY  307 

Among  these  complications  may  be  mentioned 
peritonitis,  localised,  extensive,  or  general,  which  is 
often  discovered  at-  autopsy,  with  or  without  perfora- 
tion ;  intestinal  perforation,  which  is  of  very  frequent 
occurrence  (being  found  in  12  out  of  77  autopsies  con- 
ducted by  Strong),  and  which  is  localised  principally  in 
the  neighbourhood  of  the  sigmoid  flexure  ;  thrombosis 
of  the  large  blood-vessels ;  partial  paralysis ;  infarctions, 
and  abscess  of  the  spleen,  the  brain,  etc. 

The  most  frequent  complication,  which  makes  the 
prognosis  of  amoebic  dysentery  peculiarly  gloomy,  is 
abscess  of  the  liver.  It  is  never  met  with  in  the  course 
of  bacillary  dysentery.  The  abscess  is  very  often 
localised  in  the  right  lobe,  which  is  hypertrophied. 
The  only  constant  clinical  indication  is  the  excruciating 
pain,  which  must  always  be  looked  for,  and  which  is 
provoked  by  pressing  deeply  at  any  point  in  the  region 
of  the  thorax,  principally  between  the  ribs.  When 
the  abscess  begins  to  form  the  patient  experiences  and 
complains  of  discomfort  and  pain  in  the  liver,  very 
often  radiating  to  the  right  shoulder,  and  a  painful 
heaviness  in  the  region  of  the  right  hypochondrium. 
The  swelling  may  be  apparent.  There  is  emaciation 
and  jaundice,  the  latter  in  one  case  out  of  every  four. 
There  is  now  reason  to  suspect  suppurative  hepatitis, 
especially  if  there  is  fever.  Pleurisy  of  the  base  is 
rarely  absent.  Diagnosis  is  sometimes  facilitated  by 
radiography  and,  if  needful,  by  deep  exploratory 
punctures,  but  it  is  often  difficult  to  localise  the  abscess 
if  of  small  volume  or  in  an  early  stage  of  development. 
It  is  useful  to  examine  the  blood.  In  the  course  of 
amoebic  dysentery  sometimes  a  very  appreciable 
eosinophilia  of  the  blood  is  noted  (4  to  47  per  cent.) 
(Billet,  Chantemesse  and  Rodriguez,  Dopter,  Hoyt,^ 
C.  Mathis  and  M.  Leger).  This  eosinophilia  is  not, 
however,  constant. ^    When  it  exists  its  disappearance 

^  It  has  probably  nothing  to  do  with  the  dysentery  per  se  and  more 
likely  is  due  to  helmenthic  or  other  complications.  Certainly  many 
cases  of  amoebic  dysentery  never  show  it. — Ed. 


308   DYSENTERY,  CHOLERA,  AND  TYPHUS 

enables  one  to  mark  the  moment  at  which  the  dysentery 
becomes  compUcated  by  suppurative  hepatitis.  The 
amoebic  abscess  of  the  liver,  in  short,  causes  the  dimi- 
nution or  even  the  absolute  disappearance  of  eosinophile 
leucocytes  in  the  circulating  blood. 

The  development  of  the  abscess  is  sometimes  in- 
sidious, without  increase  of  temperature,  without  any 
appreciable  pain,  and  is  marked  only  by  emaciation, 
dyspepsia,  and  vague  pains  in  the  region  of  the  liver. 
Abscess  of  the  liver  may  supervene,  although  not  always, 
in  patients  suffering  from  slight  attacks  of  dysentery 
who  have,  until  the  formation  of  the  abscess,  undergone 
no  treatment,  or  in  patients  treated  only  during  the 
acute  periods  of  the  disease — ^that  is  to  say,  in  an  in- 
sufficient manner  (Faure,  Maute).  Finally,  there  are 
cases  in  which  suppurative  hepatitis  constitutes  the 
initial  and  even  the  only  localisation  of  amoebic 
infection,  the  enteritis  having  been  absent,  or  quite 
ephemeral.  Rogers  has  noted  the  particular  frequency 
of  hepatic  abscess  in  alcoholic  subjects. 

Abscess  of  the  liver  tends  to  effect  a  spontaneous 
external  opening,  either  through  the  skin  or  the  intes- 
tine, or  into  the  peritoneum,  or  into  the  bronchi  through 
a  vomica ;  more  rarely  into  the  pelvis,  the  stomach,  etc. 

Death  often  ensues  through  cachexia  or  secondary 
infections. 

During  the  present  war  abscess  of  the  liver  has  often 
been  observed  to  occur  as  a  sequel  of  ill-defined  intestinal 
affections  treated  as  enteritis  or  "  trench  diarrhoea." 
The  exact  diagnosis  of  amoebic  dysentery  was  only  come 
to  by  the  formation  of  the  abscess  and  the  therapeutic 
success  of  emetin  (Rives  and  Huet,  Rathery  and  Bisch, 
Lian  and  Lyon-Caen,  Rist  and  Roger,  etc.). 

III.  Dysenteries  caused  by  Various  Etiological 

Agents 

We  shall  confine  ourselves  in  this  section  to  the 
enumeration  of   some   of  the   varieties   of   dysentery 


SYMPTOM  A  TOLO  GY  309 

attributed  to  various  agents,  and  some  of  which,  as 
we  have  already  said,  require  to  be  made  the  subject 
of  fresh  investigations  before  their  individuahty  can 
be  confirmed. 

Spirillum  dysentery. — Le  Dantec  has  described  a 
dysentery  in  which  microscopic  examination  of  the 
mucous  discharges  reveals  the  presence  of  a  pure 
culture  of  spirilla.  This  spirillum  dysentery  is  said 
to  be  fairly  common  in  the  south-west  of  France, 
principally  in  the  region  of  Bordeaux.  It  develops 
without  fever  or  hepatic  complications.  It  may  become 
chronic,  but  always  ends  in  recovery. 

Cocco-hacillary  dysentery, — Lesage  (in  China,  Cochin- 
China,  Algeria,  and  Toulon)  and  Metin  (in  Cochin- 
China)  have  described  two  cocco-bacilli,  very  nearly 
related,  which  may  be  isolated  from  the  blood  of 
dysenteric  patients. 

Dysentery  due  to  Balantidium  coli. — ^This  has  been 
observed  by  Strong  and  Musgrave  in  the  Philippines, 
by  Solaviev  and  Klimenko  in  Russia,  and  by  Ernrooth 
in  Finland. 

Dysentery  due  to  Bilharzia  (Schistosoma  mansoni). — 
This  has  been  observed  in  the  Congo  by  Firket.  It  is 
not  uncommon  to  find  the  eggs  of  the  parasite,  not 
only  in  the  stools  of  the  patients,  but  also  in  the 
urine.  1 

Dysentery  due  to  Chilodon  dentatus^ — Observed  by 
Guiart. 

Various  dysenteries. — Lewkowicz  and  Simonin  believe 
that  the  enterococcus  of  Thiercelin  plays  an  active  part 
in  many  dysenteriform  processes.  The  -  Bacillus 
pyocyaneus,  the  Proteus  vulgaris  (Mace,  Mougniet),  and 
other  microbes  have  also  been  incriminated. 

Finally,  dysenteries  have  been  reported  as  resulting 

^  The  original  case  was  described  by  Manson  :  a  man  from  Antigua, 
West  Indies.  It  is  excessively  rare  to  get  lateral-spined  bilharzia 
ova  in  the  urine. — Ed 

^  Chilodon  dentatus  is  a  protozoon  commonly  found  in  water.  There 
is  no  proof  that  it  can  live  as  a  parasite  or  produce  symptoms  of 
dysentery.  — Ed. 


310     DYSENTERY,  CHOLERA,  AND  TYPHUS 

from  Trichomonas  (Billet,  Simonin,  Escomel),  Cer- 
comonas,  Lamblia  intestinalis  (C.  Mathis,  C.  Fairise, 
and  Jacquot,  etc),  Tetramitus  (Chilomastix)  mesnili 
(Brumpt),  Pentatrichomonas  ardindelteili  (Derrieu  and 
Raynaud),  etc.  The  symptomatology  of  these  affections 
is  similar  to  that  of  the  other  forms.  Their  development 
is  in  general  chronic.^ 

^  The  flagellates  of  the  intestine  may  produce  diarrhoea,  though 
some  observers  even  deny  this  role  to  them.  They  certainly  do  not 
produce  dysentery  in  the  strict  sense  of  the  term. — Ed. 


CHAPTER  II 

DIAGNOSIS    OF   DYSENTERY 
I.  Diagnosis  of  the  Dysenteric  Syndrome 

It  is  necessary,  in  the  first  place,  to  diagnose  the  dysen- 
teric syndrome.  The  character  of  the  stools,  their 
frequency,  colics,  cutting  pains,  straining,  and  tenesmus, 
are  by  themselves,  when  they  are  united,  symptoms 
characteristic  enough  to  render  diagnosis  easy.  But 
it  must  not  be  forgotten  that  there  are  cases  of 
larval  dysenteries,  hardly  defined,  of  which  ''  trench 
diarrhoea  "  is  sometimes  one  of  the  forms,  in  the  course 
of  which  the  syndrome  is  represer^ted  by  only  one  or 
two  symptoms,  which  are  not  always  pathognomic. 
The  development  of  these  cases,  the  complications 
which  accompany  them,  ^nd  notably  the  occurrence  of 
hepatic  abscesses,  permit  of  the  establishment  of  a 
retrospective  diagnosis. 

It  must  be  remembered  that  rectal  polypus  in  children, 
hcemorrhoids  in  adults,  and  neoplasms  in  the  aged,  may 
provoke  sanguinolent  stools,  tenesmus,  and  the  expul- 
sion of  mucous  discharges. 

Retroflexions  and  retro-uterine  phlegmons  may,  by 
their  concomitant  symptoms,  simulate  attacks  of 
dysentery,  and  the  same  is  true  of  affections  of  the 
bladder,  especially  of  lithiasis. 

The  pernicious  dysenteriform  access  [malarial  dysen- 
tery], the  existence  of  which  is  contested  by  certain 
authors,  presents  a  great  similarity  to  dysentery.  The 
stools  may  be  mixed  with  blood  and  mucus.  There 
is  straining,  colic  and  tenesmus,  and  the  temperature 
is  often  very  high.  Under  treatment  by  quinine  and 
opium  the   intestinal   flux   is   replaced    by   abundant 

311 


313    DYSENTERY,  CHOLERA,  AND  TYPHUS 

perspiration,  the  end  of  the  access  is  determined,  and 
the  diagnosis  established.  It  is  possible  that  the 
symptoms  observed  may  be  due  to  an  association  of 
dysentery  and  malaria.  The  examination  of  the  blood 
and  the  stools  yield  valuable  indications. 

The  chronic  diarrhoea  of  hot  countries  (synonyms  : 
Cochin-China  diarrhoea,  tropical  diarrhoea,  sprue,  spruw, 
pilosis  linguae,  white  diarrhoea,  tropical  aphthae,  Ceylon 
sore  mouth)  sometimes  presents  certain  of  the  char- 
acteristics of  chronic  dysentery.  According  to  Sir 
Patrick  Manson,  it  may  be  primary  or  secondary  to 
other  infections,  notably  to  chronic  dysentery.  It  is 
characterised  by  irregular  alternations  of  exacerbation 
and  comparative  quiescence  of  symptoms,  by  erosive 
and  inflammatory  lesions  of  the  tongue,  mouth,  and 
pharynx — very  painful  erosions,  causing  abundant 
salivation ;  by  dyspepsia,  usually  very  severe,  accom- 
panied by  abdominal  tympanism,  borborygmi  and 
vomiting,  with  or  without  nausea  ;  by  the  evacuation 
of  discoloured  stools,  which  are  extraordinarily  abund- 
ant, frothy  and  fetid,  without  tenesmus,  and  without 
mucous  discharges  or  blood  ;  by  extreme  emaciation, 
anaemia,  and  a  tendency  to  relapse  on  the  occasion  of 
the  slightest  exciting  cause  (exertion,  or  a  chill,  or  a 
slight  departure  from  diet,  etc.). 

All  these  specific  symptoms  will,  as  a  rule,  enable  the 
physician  to  make  a  diagnosis. 

Cases  of  amoebic  dysentery,  associated  with  cholera 
(Yakimov  and  Damidov)  and  with  typhoid  fever  or 
typhus,  have  been  reported,  particularly  in  time  of  war. 
Laboratory  research  alone  can  enable  one  to  arrive  at 
a  correct  diagnosis  in  such  cases. 

Subcutaneous  injections  of  salts  of  mercury  and  the 
ingestion,  voluntary  or  otherwise,  of  certain  berries 
(notably  that  of  one  of  the  Euphorbiacece,  Hura  crepi- 
tans) may  simulate  a  dysenteric  attack  (Pierre). 


DIAGNOSIS  OF  DYSENTERY  313 


II.  Diagnosis  of  the  Nature  of  Dysentery 

In  the  presence  of  a  plainly  characterised  dysenteric 
syndrome,  one  should  always  be  able  to  determine  its 
cause.  Clinical  examination  by  itself  will  set  one  on 
the  right  road.  Bacillary  dysentery,  it  will  be  re- 
membered, often  develops,  in  cases  of  average  or 
extreme  gravity,  with  a  more  or  less  elevated  tem- 
perature, although  this  is  not  constantly  the  case, 
while  amoebic  dysentery  is  generally  apyretic,  except 
when  complications  are  present.  The  chronic  develop- 
ment of  the  disease  and  the  knowledge  that  it  is 
epidemic  (in  hot  countries)  enables  us  to  form  certain 
presumptions,  but  bacteriological  examination  is  always 
necessary. 

Sero-diagnosis  may  be  useful.  The  serum  of  patients 
suffering  from  bacillary  dysentery  habitually  agglutin- 
ates the  dysentery  bacillus  which  has  caused  the  in- 
testinal infection,  but  it  agglutinates  no  other  bacillus. 
In  cases  of  medium  or  extreme  severity,  the  agglutina- 
tion does  not  appear  until  about  the  eighth  or  tenth  day 
of  the  disease.  It  lasts  as  long  as  the  disease  lasts,  is 
observed  during  convalescence,  and  often  persists  until 
two  or  three  months  after  recovery.  The  agglutina- 
tion index  varies  from  ^^  ^^  ilu-  ^^  slight  forms  of 
dysentery  agglutination  is,  as  a  rule,  absent,  for 
such  cases  recover  before  the  agglutinative  power  of 
the  serum  can  make  its  appearance.  If  they  are 
prolonged  it  may  appear,  even  in  cases  of  simple 
diarrhoea  occurring  during  an  epidemic,  side  by  side 
with  well-defined  attacks  of  dysentery  (Braun,  Job, 
Dopter). 

In  cases  of  mixed  infection  by  dysenteric  amoebse 
and  bacilli,  the  agglutinative  power  of  the  serum  may 
appear  under  ordinary  conditions. 

The  following  table  summarises  the  chief  differential 
characteristics  of  amoebic  dysentery  and  bacillary 
dysentery. 


314  DYSENTERY,  CHOLERA,  AND  TYPHUS 

Amoebic  Dysentery  Bacillary  Dysentery 

Etiology 

Pathogenic   amoeba,    inoculable  Dysentery  bacilli, 

into  the  rectum  of  cats. 

Usual  Methods  of  Propagation 


More     particularly,     drinking 
water. 

Direct  contagion. 

Contagion  by  encysted  forms. 


Direct  contagion. 

Indirect  contagion,  from  stools 
(latrines),  flies,  vegetables,  in- 
fected soil,  manure,  dust,  drinking 
water. 


Epidemiology 


A  disease  of  hot  or  tropical 
countries,  where  it  is  endemic. 
Prevalent  in  summer  and  winter. 
Indo-China,  Tonkin,  Saigon, 
United  States,  Brazil,  Philippine 
Islands,  Cuba,  South  America, 
Madagascar,  Egypt,  Sudan, 
Senegal,  Morocco  [India],  etc. 


A  disease  prevailing  chiefly 
in  summer  and  in  temperate 
countries ;  less  frequent  in  hot 
or  tropical  countries. 

Occasionally  sporadic. 

Usually  epidemic,  spreading 
rapidly,  and  highly  contagious. 

Prevalent  in  late  summer  and 
autumn. 


Clinical  Symptoms 


Tendency  to  chronicity. 

Immunity  does  not  result  from 
a  previous  attack. 

Hepatic  abscesses  are  frequent. 

Serum  does  not  agglutinate 
dysentery  bacilli. 

Alkaline  evacuations. 

Eosinophilia  [sometimes]. 


Onset  sudden ,  development 
acute,  sometimes  chronic. 

Previous  altack  confers  im- 
munity. 

No  hepatic  suppuration. 

Serum  agglutinates  dysentery 
bacilli. 

The  dejecta  are  acid  or  neutral. 

Eosinophilia  absent. 


Anatomical  Lesions 


Deep  lesions  often  occur ;  ragged 
ulcers  with  detached  [undermined] 
edges,  localised  in  the  large 
intestine. 


Lesions  extending  over  the 
whole  of  the  large  intestine,  and 
often  to  the  lower  portion  of  the 
ileum. 

Superficial  lesions :  Yellow  or 
greyish  erosive  spots,  with  hyper- 
aemia  of  the  mucous  membranes. 


An  early  and  exact  diagnosis  can  be  established  only 
by  means  of  a  simultaneous  search  for  the  incriminated 
parasites  in  the  stools.     In  all  cases  of  dysentery,  there- 


DIAGNOSIS  OF  DYSENTERY  315 

fore,  a  certain  amount  of  systematic  research  must  be 
undertaken  in  the  laboratory. 

Laboratory  Research. — These  investigations  will  com- 
prise microscopic  investigations  with  and  without 
staining  and  cultivation.  The  former  will  permit  of 
the  cytological  examination  of  the  mucous  discharges, 
and  the  discovery  of  amoebae  or  amoebic  cysts  ;  the 
latter  will  enable  the  investigator  to  isolate  and  identify 
the  dysentery  bacilli  and  the  germs  which  may  be 
associated  with  them. 

Microscopic  examination  should  deal  with  faeces  very 
recently  passed.  By  means  of  spreading  and  separat- 
ing, smears  may  be  taken  from  the  most  purulent 
portions  of  the  mucous  discharges.  These  smears  may 
be  fixed  and  coloured  by  the  ordinary  cytological 
methods  (fixation  by  alcohol  and  ether,  stained  with 
thionin  and  eosin,  hematein  and  eosin,  Giemsa's  stain, 
etc.).  In  the  case  of  bacillary  dysentery  the  prepara- 
tions will  show  very  large  numbers  of  neutrophile  poly- 
morphonuclear leucocytes,  normal  or  but  slightly 
abnormal  mononuclear  leucocytes,  and  a  varying 
number  of  bacilli. 

In  amoebic  dysentery  the  preparations  of  mucus 
should  be  examined  in  the  fresh  state,  between  slide  and 
cover-glass,  taking  care  not  to  crush  them  unduly. 
Far  fewer  polymorphonuclear  leucocytes  occur  than 
in  bacillary  dysentery,  but  they  are  greatly  altered  ; 
eosinophile  leucocytes  are  sometimes  found  among 
them  in  considerable  numbers,  and  the  preparations  are 
very  rich  in  various  bacteria,  infusoria,  etc.  The 
number  of  these  various  elements  is  such  that  even  if 
we  do  not  meet  with  amoebae  we  may  sometimes  pre- 
sume the  diagnosis  to  be  that  of  amoebic  dysentery. 
Only  the  discovery  of  amoebae  or  their  cysts  can 
establish  the  diagnosis  with  certainty  however. 

Certain  writers  advise  the  passing  of  the  stools  into 
warmed  vessels.  H.  Vincent  has  ascertained  that  the 
amoebae  remain  motile  for  ten  to  thirty  minutes,  some- 
times   for    an    hour    even,    at    the    temperature    of 


^Ib 


Explanation  of  the  Plate 

1,  2,  3. — Living  dysentery  amcebse.     [E.  histolytica.] 

4. — Non-pathogenic  living  amoebae.     [E.  coli.] 

5,  6,  7,  8,  9,  10,  11. — Dysentery  amcebse.     Stained  with  iron  hema- 
toxylin (from  a  preparation  by  Dr  Langeron). 

12. — Non-pathogenic  amoebae.     Stained  by  iron  hematoxylin. 

13,  14,  15,  16,  17. — Cysts  of  dysentery  amoebae  [E.  histolytica]  with 
four  nuclei ;  15,  16,  17,  containing  chromatoids. 

18. — Cysts  of  non-pathogenic  amwbai  with  eight  nuclei      [E.  coli.] 
One  of  these  cysts  contains  chromatoids. 

19. — Balantidium,  coli. 

20. — Lamhlia  [Q\a.v(X\aJ\ intestinalis . 

21a. — Cysts  of  Lamblid  intestinalis. 

21b. — Cysts    of    Lamhlia    intestinalis.     Stained    with    iron    haema- 
toxylin. 

22. — Trichomonas  intestinalis, 

23. — Egg  of  Schistosoma  mansoni. 

» 

24. — Tetramitus  [Ghilomastix]'  mesnili. 


317 


318       DYSENTERY,  CHOLERA,  AND  TYPHUS 

specific  amoeba  of  dysentery  by  the  name  of  Amoeba 
coll  dysenterice,  or  that  of  Entamoeba^  the  latter  being 
proposed  by  Councilman  and  Lafleur.  E.  histolytica 
and  E.  tetragena  are  to-day  regarded  as  phases  of 
E.  dy sentence  (Job  and  Hirtzmann,  C.  Mathis  and 
L.  Mercier,  etc.),  not  as  distinct  species. 

In  Morocco  Job  and  Hirtzmann  have  usually  found 
the  E.  tetragena  at  the  moment  of  the  dysenteric  crisis. 
It  is  this  type  also — long  regarded  as  more  peculiar  to 
African  regions — which  has  been  reported  in  France  by 
Ravaut  and  Krolunitsky. 

The  E.  histolytica  type  is  characterised  by  its  ex- 
tremely active  movements — so  active  that  one  cannot 
always  draw  the  contours  of  the  transparent  chamber. 
It  emits  pseudopodia  in  considerable  numbers,  which  are 
rapidly  protruded  and  withdrawn. 

The  endoplasm,  a  greenish-yellow,  is  crammed  with 
cellular  and  alimentary  debris,  and  especially  with  red 
corpuscles. 

It  also  contains  bacteria,  and,  more  rarely,  chromatoid 
bodies. 

The  ectoplasm  is  transparent  and  refractile. 

The  living  amoeba  appears  to  be  without  a  nucleus, 
but  when  its  movements  become  less  rapid,  or  cease, 
the  nucleus  appears,  round,  and  provided  with  a 
nucleolus.  The  endoplasm  and  the  ectoplasm  seem  less 
differentiated,  and  one  can  plainly  recognise  the  red 
corpuscles  or  their  debris. 

In  fixed  and  stained  preparations  E.  histolytica  appears 
round,  confined  by  a  clear  outline,  and  containing 
numerous  vacuoles  which  enclose  red  corpuscles  ;  the 
nucleus  appears  round  and  excentric,  with  a  peripheral 
ring  of  chromatin  granules  and  a  single  centriole. 

E.  tetragena  ^  is  found  only  in  the  faecal  evacuations 
(Ravaut  and  Krolunitsky).  Its  movements  are  much 
less  rapid  than  those  of  the  amoeba  just  mentioned, 

^  The  small  forms  found  in  the  faeces  are  usually  spoken  of  as  the 
E.  miinUa  type  by  English  authorities  ;  they  are  generally  regarded  as 
the  immediate  precursors  of  the  cysts. — Ed. 


DIAGNOSIS  OF  DYSENTERY  319 

the  endoplasm  and  the  ectoplasm  are  less  distinct,  the 
red  corpuscles  included  are  less  numerous,  and  the 
nucleus  is  very  apparent. 

In  the  immobile  condition  it  is  hardly  to  be  dis- 
tinguished from  E.  histolytica  when  the  latter  has 
become  immobile. 

In  addition  to  the  pathogenic  amoeba  one  very  often 
meets  with  another,  E.  coli,  which  is  regarded  as  normal 
to  the  colon.  Its  movements  are  very  slow,  the  endo- 
plasm and  the  ectoplasm  are  poorly  differentiated,  the 
nucleus  is  very  plainly  visible,  and  it  encloses  no  red 
corpuscles. 

In  fixed  and  stained  preparations  the  nucleus  presents 
the  same  structure  as  in  E.  dysenterice,  but  there  are 
generally  several  centrioles. 

The  living  amoebae  are  easily  recognisable,  but  when 
the  stools  are  examined  some  hours  after  being  passed, 
they  have  become  immobile.  It  is  then  more  prudent 
to  search  for  the  cysts.  While  the  amoebse  are  found 
in  the  living  condition  only  during  crises  the  cysts  are 
[may  be. — Ed.]  visible  during  the  whole  course  of  the 
disease.  They  are  sought  for  by  direct  examination, 
between  slide  and  cover-glass,  with  or  without  colora- 
tion. According  to  Langeron,  the  addition  of  a  little 
Lugol's  solution  to  the  preparation  notably  facilitates 
the  examination.  C.  Mathis  fixes  fresh,  undried  pre- 
parations by  exposure  to  the  vapour  of  osmic  acid 
(1  per  cent.)  for  thirty  seconds.  He  then  stains,  for  a 
few  seconds,  with  hgematoxylin  (1  in  200).  The 
envelop  and  the  nuclei  of  the  cysts  are  stained  a  deep 
brown,  thus  becoming  plainly  visible. 

To  identify  the  cysts  we  must  note  their  dimensions 
and  the  number  of  their  nuclei. 

The  cysts  of  Entamceha  dysentericE  \E.  histolytica  of 
English  authors — Ed.]  measure  at  most  10-14  ii  in 
diameter,  and  possess  1  to  4  nuclei,  never  more  (E.  Job 
and  L.  Hirtzmann).  In  the  protoplasm  one  very  often 
sees  agglomerations  of  a  refracting  substance,  which 
occurs  in  thick  rod-like  bodies  or  irregular  masses ;  it  is 


320   DYSENTERY,  CHOLERA,  AND  TYPHUS 

known  as  chromidium,  and  according  to  C.  Mathis  is 
characteristic  of  this  variety  of  cysts. 

The  cysts  of  E.  coli  (non-pathogenic)  measure  16-25  /x 
and  even  more;  they  possess  1  to  8  nuclei.  The  cysts 
of  E.  dysenteries  [E.  histolytica],  Hke  those  of  the  non- 
pathogenic amoeba,  may  or  may  not  contain  chromatoid 
bodies. 

For  purposes  of  diagnosis  one  should  observe  only 
the  ripe  cysts — ^that  is,  those  containing  4  and  8 
nuclei. 

The  number  of  cysts  is  very  variable  ;  sometimes  very 
abundant  in  each  preparation,  they  are,  on  the  con- 
trary, very  rare  in  other  cases.  Ravaut  and  Krolunitsky 
facilitate  their  elimination  by  the  artificial  production 
of  a  temporary  attack  of  enteritis,  either  by  means  of 
a  saline  purgative  or  a  saline  enema,  or,  better  still,  by 
the  intravenous  injection  of  1  to  4  centigrammes  of 
cyanide  of  mercury. 

Noc,  with  the  same  object  in  view,  administers  an 
enema  of  boiled  water  (500  c.c).  When  this  has  taken 
effect  he  employs  an  irrigation  or  instillation,  lasting 
thirty  minutes,  with  |  per  cent,  solution  of  thymol  (in 
boiled  water). 

A.  Maute  administers,  in  the  morning,  an  irrigation 
with  : 

Iodine         .  .  .  .  .  .1  gramme 

Iodide  of  potassium  .  .  .  .2  grammes 

Water         .  .  .  .  .  .1  litre 

The  amoebge  and  cysts  are  looked  for  in  the 
diarrhoeal,  or  merely  soft,  or  sometimes  even  formed 
stools,  which  the  patient  passes  during  the  evening  or 
the  next  morning. 

The  cysts  remain  intact  in  the  stools  for  at  least 
two  days.  If  the  investigation  has  to  be  undertaken 
later  than  this,  the  addition  of  formol  will  preserve  them 
perfectly. 

Maute  attaches  very  great  practical  importance  to 
the  investigation  of  associated  parasites,   the  super- 


DIAGNOSIS  OF  DYSENTERY  321 

addition  of  these  seeming  to  maintain  and  augment  the 
resistance  of  the  amoebae. 

One  should,  according  to  him,  look  for  protozoa  (the 
trichomonas  especially)  and  intestinal  wonns  (ascaris, 
trichocephalus,  etc.). 

The  final  disappearance  of  cysts  in  the  stools  is  the 
only  criterion  which  we  at  present  possess  of  recovery 
from  amoebic  dysentery. 

The  bacteriological  diagnosis  of  bacillary  dysentery 
necessitates  the  culture  and  isolation  of  the  bacillus, 
as  well  as  its  identification. 

1.  Culture.  Isolation. — A  flake  of  mucous  or  muco- 
purulent matter  is  washed  several  times  in  sterile 
bouillon  or  physiological  serum,  in  order  to  free  it 
of  gross  impurities. 

The  culture  is  then  made  on  several  Petri's  dishes, 
into  which  some  litmus  lactose  agar,  and  also  Endo's 
agar,  has  been  poured.  The  agar  is  inoculated  by 
spreading  the  flake  of  mucus  on  it  and  moving  it  gently 
to  and  fro  by  means  of  a  platinum  wire  or  a  bent  glass 
rod.  After  twenty-four  hours  in  the  incubator,  at  a 
temperature  of  37°  C,  the  inoculated  portions  are 
examined.  On  the  agar  containing  litmus,  red  and  blue 
colonies  will  be  found ;  on  the  Endo's  medium  some 
red  colonies  will  be  seen,  and  others  which  are  colourless. 
The  red  colonies  are  eliminated  ;  it  is  in  the  blue  and 
colourless  colonies  that  the  dysentery  bacilli  will  be 
found. 

2.  Identification. — ^The  dysentery  bacillus  is  a  short 
rod-shaped  bacillus,  rounded  at  its  extremities,  easily 
absorbing  all  the  aniline  stains,  but  negative  to  Gram's 
stain.  It  does  not  form  spores,  but  shows  polar 
granulations.  Its  movements  are  feeble,  confined  as  a 
rule  to  slight  oscillations  like  those  of  a  compass-needle 
settling  to  the  north.  This  motility,  which  Flexner  ob- 
served in  his  bacillus,  is  very  slight  even  in  the  case  of  recent 
cultures  made  directly  from  dysenteric  stools ;  in  sub- 
cultures it  progressively  diminishes,  finally  disappearing. 


322   DYSENTERY,  CHOLERA,  AND  TYPHUS 

Principal  Differential  Characteristics  of  the  Four  Types 
OF  Dysenteric  Bacilli 


BACILLUS 


Shiga 


Flexner 


His  (Y) 


Strong 


Production 
indol 


of 


No  indol 


Litmus  milk 


Indol 


Indol 


Indol 


Reddens  very  j  Reddens  more 
slightly :         i    perceptibly 


As  Flexner's 


As  Flexner's 


turns  ame- 
thyst after 
twenty  -  four 
hours 


Neutral  red  media        No  change 


Litmus  agar  and 
dulcite,  litmus 
agar  and  lactose 


Litmus  agar  and 
glucose,  litmus 
agar  and  galac- 
tose,litmusagar 
and  Itevulose 


Litmus  agar  and 
mannite,  litmus 
agar  and  raffl- 
nose 


Litmus  agar  and 
maltose 


Agglutination 


Experimental 
pathogenic    ac- 
tion 


No    fermenta- 
tion 


Turns  red 


No  fermenta- 
tion 


Turns  an  in- 
constant red 
after  several 
days 


With      Shiga 
serum  only 


Subcutaneous 
injection  pro- 
duces dysen- 
tery in  the 
rabbit,  dog, 
rat,  and 
mouse,  but 
not  in  the 
guinea-pig 


than  Shiga's 


No  change 


No  change 


No    fermenta- 
tion 


No    fermenta- 
tion 


Turns  red 


Turns  red 


Turns  red 


Turns  red 


Turns  red 


Agglutination 
with  the 
Flexner  and 
y  serums, 
but  not 
with  Shiga 
and  Strong 
serums 


Subcutaneous 
injection  pro- 
duces  no 
pathogenic 
results.  In- 
jected under 
the  periton- 
eum it  pro- 
duces fatal 
peritonitis  in 
the  guinea- 
pig,  rat,  and 
mouse 


Red  tinge  ob- 
tained rarely 
and  with 
difficulty 


No  change 


Same  as 
Flexner's 


Same  as 
Flexner's 


No    fermenta- 
tion 


Turns  red 


Turns  red 


Change  to  red 
capricious 
and  slow 


Agglutinated 
only  by 
Strong  serum 


Same  as 
Flexner's 


DIAGNOSIS  OF  DYSENTERY  323 

According  to  Sir  Patrick  Manson,  Shiga's  bacillus 
displays  two  to  six  terminal  flagella,  rather  short  and 
thick;  those  of  Flexner's  bacillus  are  said  to  be 
longer. 

The  dysentery  bacillus  does  not  coagulate  milk ; 
on  gelatine  the  isolated  cultures  are  shallow  and  trans- 
lucid,  their  edges  being  "  pinked,"  while  they  are 
crossed  by  furrows  which  give  them  the  appearance  of 
vine-leaves. 

There  are  races  of  dysenteric  bacilli,  just  as  there 
are  races  of  cholera  vibrios  and  typhoid  bacilli.  These 
races  comprise  types  which  are  steadily  increasing  in 
number.  At  the  present  time  there  are  only  four  races 
which  present  characteristics  definite  e:pough  to  enable 
us,  whenever  a  germ  is  isolated,  to  refer  it  to  one  of 
them  for  identification.  Between  these  four  types 
there  are  a  great  number  of  varieties  which  are  more 
or  less  differentiated  one  from  another. 

In  addition  to  these  we  also  encounter  a  certain 
number  of  so-called  pseudo-dysentery  bacilli,  which, 
by  their  histological  characteristics  and  their  reactions 
are  more  or  less  differentiated  from  the  true  dysentery 
bacilli. 

The  table  given  on  p.  322  summarises  the  essential 
characteristics  of  the  four  principal  types. 


CHAPTER  III 

THE  TREATMENT  OF  DYSENTERY 

The  diagnosis  of  dysentery  being  established,  the 
patient  should  immediately  be  put  to  bed  and  kept 
warm,  and  as  far  as  possible  be  prevented  from 
leaving  his  bed,  even  to  visit  the  commode.  The 
alimentary  canal  should  be  kept  in  a  state  of  repose. 

All  solid  food  must  be  suppressed.  Foods  must  be 
selected  which,  while  possessing  high  nutritive  qualities, 
leave  a  minimum  of  faecal  residue.  Milk,  beef-tea, 
white  of  egg,  barley  water  or  rice  water,  and  peptonised 
milk  should  constitute  the  basis  of  alimentation 
(Manson). 

Vegetable  bouillon,  which  has  yielded  such  good 
results  in  the  treatment  of  diarrhoea  in  children,  has 
been  employed  with  success  by  Boudet.  To  assuage 
thirst,  weak  lukewarm  tea  is  welcomed  by  the  patient. 

Alcohol  and  alcoholic  beverages  are  only  to  be  given 
in  cases  where  collapse  is  to  be  feared. 

Liquid  nourishment^  more  or  less  abundant  according 
to  the  case,  and  at  times  bordering  upon  full  diet, 
should  be  continued  until  the  stools  are  no  longer 
numerous,  and  simply  diarrhceal.  At  this  stage  one 
may  give  very  light  purSes  of  dry  vegetables  or  potatoes. 
Meat  diet  is  to  be  resumed  only  with  the  utmost 
prudence. 

Treatment  must  be  subordinate  to  the  diagnosis 
given  by  the  laboratory.  Some  of  the  various  cases 
which  may  present  themselves  will  now  be  considered. 

1.  In  Cases  of  Bacillary  Dysentery. — ^We  now  have  a 
specific  treatment  for  this  form  of  dysentery.  Shiga, 
in  Japan,  in  1898,  was  the  first  to  utilise  the  curative 

324 


TREATMENT  OF  DYSENTERY  325 

properties  of  the  serum  of  animals  immunised  against 
the  dysentery  bacillus.  Simultaneously  Rosenthal 
and  Gabritchevski  in  Moscow,  Vaillard  and  Dopter,  and 
Auche  and  Coyne  in  France  were  undertaking  investiga- 
tions of  the  same  nature.  Vaillard  and  Dopter,  by 
weekly  inoculations  of  living  cultures  of  dysentery 
bacilli  into  the  veins  of  the  horse,  obtained  a  serum 
which  possesses  preventive  and  curative  effects  in 
cases  of  experimental  dysentery  in  animals. 

Injected  into  the  human  su^erer  from  .bacillary 
dysentery  this  serum  diminishes  mortality,  attenuating 
and  causing  the  rapid  disappearance  of  the  dysenteric 
phenomena.  A  few  hours  after  the  injection  of  the 
serum  the  patient  usually  experiences  a  genuine  feeling 
of  improvement,  the  abdominal  pains,  the  tenesmus 
and  the  straining  already  abating,  and,  except  in  very 
serious  cases,  they  almost  always  disappear  during  the 
ensuing  twenty-four  hours.  Recovery  takes  place  in 
forty-eight  hours,  five  or  six  days  or  ten  to  fifteen  days, 
accordingly  as  the  case  is  slight,  average,  severe,  or  very 
severe.  Convalescence  is  shorter  and  easier.  The 
serum  is  given  by  subcutaneous  injections.  Its  effects 
are  more  rapid  and  decisive  in  proportion  as  it  is 
administered  more  promptly  after  the  onset  of  the 
disease.  The  dose  varies  according  to  the  moment  of 
intervention,  the  severity  of  the  attack,  and  the  age 
of  the  patient.  The  following  indications  are  given 
by  the  inventors  of  the  serum  treatment :  For  adults 
in  dysentery  of  average  severity,  taken  at  the.  outset, 
20  c.c.  will  usually  suffice  to  produce  an  immediate 
arrest  of  all  the  symptoms.  If  these  still  persist  after 
the  lapse  of  twenty-four  hours,  another  injection  of 
20  c.c.  should  be  given.  In  severe  forms,  or  cases  of 
several  days'  standing,  a  third  injection  of  10  c.c. 
will  be  useful. 

In  serious  cases  40  to  60  c.c.  should  be  injected  at 
once,  and  the  physician  should  not  hesitate  to  repeat 
the  injection  daily,  even  to  the  length  of  administering 
a  dose  of  100  c.c.  per  diem,  in  two  injections,  until 


326   DYSENTERY,  CHOLERA,  AND  TYPHUS 

the  intestinal  disturbances  abate.  The  treatment  is 
then  carefully  continued,  with  diminishing  doses,  until 
the  number  of  stools  falls  -  to  a  few  in  the  course  of 
the  twenty-four  hours.    ^ 

For  children  the  above  doses  are  to  be  reduced  by 
one-half,  two-thirds,  or  three-quarters,  according  to  age. 

In  certain  cases  which  are  refractory  to  serotherapy, 
and  in  chronic  forms,  enemas  of  serum,  reaching  as 
high  a  point  of  the  colon  as  possible,  have  been  re- 
commended. 

Medical  treatment  hy  means  of  Segond's  pills  (vide, 
p.  329)  (2  to  6  per  diem),  or  by  sulphate  of  sodium 
(10  grammes  per  diem),  together  with  opium,  leads  to 
a  quick  recovery  in  dysenteries  of  average  severity, 
in  default  of  the  serum  treatment. 

2.  In  Cases  of  Amoebic  Dysentery. — Hydrochloride  of 
emetin  is  at  present  regarded  as  the  most  active  remedy 
in  the  treatment  of  amoebic  dysentery,  but  although 
it  acts  rapidly  on  the  inter-organic  amoebae  lodged  in 
the  liver  or  the  walls  of  the  intestine,  it  has  no  action 
on  the  extra-organic  amoebae — that  is,  those  which  are 
free  in  the  intestine.  Moreover,  the  treatment  is 
often  followed  by  relapse.  It  has  been  proposed  to 
continue  the  treatment  by  subcutaneous  injections 
(Chauffard)  and  also  to  complete  the  cure  by  injection 
by  means  of  local  treatment  (irrigations)  which  would 
reach  the  amoebae  remaining  in  the  intestine,  but  this 
latter  treatment  is  usually  ineffectual. 

Certain  writers  give  two  intravenous  injections  of 
0-15  to  0-20  grammes  of  hydrochloride  of  emetin  in 
100  c.c.  of  physiological  serum,  and  then,  during  a 
period  of  one  or  two  weeks,  subcutaneous  injections 
of  0-10  to  0-12  grammes.  Lastly,  supplementary 
cures  are  administered  every  three  or  four  weeks. 
The  dejecta  are  examined  periodically  for  some 
months  with  a  view  to  the  discovery  of  amoebic 
cysts,  after  an  iodated  enema. 

Maute,  during  the  first  three  or  four  days,  gives  two 


TREATMENT  OF  DYSENTERY  327 

subcutaneous  injections  of  hydrochloride  of  emetin, 
the  dose  being  4  centigrammes  per  injection  ;  then, 
during  the  three  or  four  subsequent  days,  he  gives  a 
single  injection. 

Generally  speaking,  the  dysenteric  phase  is  then  over, 
and  the  patient  no  longer  passes  more  than  one  or  two 
stools  in  the  day.  If,  on  the  contrary,  the  diarrhoea 
persists,  one  should  suspect  parasitic  associations,  and 
should  look  for  them  and  treat  them  (with  worm-seed, 
santonin,  thymol,  turpentine,  etc.,  according  to  the 
case). 

Maute  then  gives  five  series  of  five  injections,  each 
leaving  an  interval  of  a  week  between  each  series.  If 
after  the  administration  of  an  iodated  lavage  he  dis- 
covers no  more  cysts  in  the  stools,  he  regards  the 
patient  as  cured.  Despite  these  long  series  of  injec- 
tions, however,  it  often  happens  that  one  still  discovers 
evidence  of  amoebic  development. 

In  these  cases,  following  the  method  of  Ravaut  and 
Krolunitsky,  Maute  employs  novarsenobenzol.  Every 
six  or  seven  days  he  gives  an  injection  of  -15,  -30,  45, 
•60,  to  75  grammes.  If  cysts  are  still  found  in  the 
stools  a  few  days  after  the  end  of  the  treatment,  he 
gives  two  series  of  five  injections  each  of  emetin  (two 
injections  of  8  centigrammes  and  three  of  4  centi- 
grammes), each  series  following  the  preceding  series  at 
an  interval  of  eight  days.  About  6  per  cent,  of  dysen- 
teric subjects  are  still  infected  after  this  treatment. 
Maute  is  of  opinion  that  it  is  to  the  interest  of  such 
patients  to  continue  the  treatment  by  emetin  and 
novarsenobenzol. 

This  is  also  the  opinion  of  Milian,  who  employs 
hydrochloride  of  emetin  and  "606"  concurrently;  of 
Ravaut  and  Krolunitsky,  who  employ  arsenobenzol, 
and  of  Noc,  who  employs  "  914,"  which  he  regards  as  a 
remedy  of  great  utility  in  improving  the  general  con- 
dition, superior  to  the  ordinary  arsenical  compounds. 

Despite  its  incontestable  value,  hydrochloride  of 
emetin  does  not  always  succeed.     It  has  little  or  no 


328   DYSENTERY,  CHOLERA,  AND  TYPHUS 

effect  on  the  cysts.  ^  In  the  chronic  and  refractory  forms 
of  amoebic  dysentery  the  physician  may  profitably 
resort  to  the  treatment  indicated  on  p.  330 

3.  In  Cases  of  Mixed  Dysentery,  Bacillary  and  Amoebic. — 

The  physician  will  successively  administer  injections 
of  hydrochloride  of  emetin  and  of  anti-dysenteric  serum, 
and  will  be  guided  by  the  indications  already  given. 

4.  {a)  When  the  Results  of  Examination  in  the  Laboratory 
are  Negative.  —  Reserving  treatment  by  emetin  and 
serum  for  serious  cases,  the  physician  may  resort  to  the 
older  remedies.  There  are  a  certain  number  of  remedies 
which  gave  proof  of  their  value  in  the  days  when 
etiological  diagnosis  was  unknown.  These  remedies 
may  be  recomm^ided  either  as  auxiliary  to  the  treat- 
ments reputed  to  be  specific,  or  in  cases  where,  for 
whatever  reason,  the  physician  cannot  or  does  not  wish 
to  employ  the  specific  treatment.  These  are  :  ipec- 
acuanha, the  saline  purgatives,  calomel,  and  opium. 

Ipecacuanha  may  be  administered  in  several  ways  : 
alone,  or  in  association  with  other  drugs,  notably  with 
calomel  and  opium.  Alone,  it  is  given  in  fractional 
doses,  according  to  the  so-called  Brazilian  method. 
It  is  prepared  and  administered  as  follows : — 250 
grammes  of  boiling  water  are  poured  upon  4  to  8 
grammes  of  the  powdered  root ;  this  is  left  undisturbed 
for  twelve  hours,  then  decanted ;  in  the  same  way 
a  second  and  a  third  infusion  is  made,  followed  by 
maceration. 

Each  of  these  infusions  is  taken  per  day,  at  the  rate 
of  a  spoonful  every  hour.     The  first  infusion  sometimes 

^  Recent  researches  have  shown  that  a  large  proportion  of  cases 
treated  by  emetine  hydrochloride  relapse  and  become  chronic  cyst 
carriers.  Oral  administration  of  emetine,  in  the  form  of  Emetine 
bismuth  iodide  grs.  iij.  nightly  for  twelve  nights — e.g.  36  grains  in  a 
course — has  l)een  found  to  be  much  more  efficacious  in  sterilising  cases, 
and  recent  reports  by  Dobell  claim  80  to  90  per  cent,  of  cures  by  this 
method.  Alcresta  ipecacuanha  has  also  been  tried  by  Stephens,  and 
Wcnyon  suggests  a  combined  oral  and  hypodermic  treatment  with 
emetine  hydrochloride. — Ed. 


TREATMENT  OF  DYSENTERY  329 

causes  vomiting,  and  often  numerous  stools.  The 
second  rarely  produces  vomiting,  but  more  frequently 
nausea  ;  it  does  not  perceptibly  affect  the  number  of 
stools.  The  third,  as  a  rule,  produces  no  incidental 
effects. 

Saline  purgatives,  sulphate  of  sodium  in  particular, 
are  in  current  use.  They  may  be  administered  until 
the  stools  contain  no  more  mucus  and  have  become 
faecal.  The  treatment  commences  with  30  grammes 
of  sulphate  of  sodium,  progressively  diminishing  doses 
being  given  day  by  day,  or  small  doses  of  5  to  10 
grammes  may  be  administered,  repeated  several  times 
in  the  day,  until  the  purgative  effect  is  produced,  or 
15  grammes  may  be  given  for  the  first  two  days,  and 
10  grammes  the  third  and  fourth  days. 

Segond's  pills  may  be  tried,  their  composition  being 
as  follows  : 

Ipecacuanha  (pulv. )  .  .  .  'O '05  grammes 

Calomel       .  .  .  .  .  0-02        „ 

Extract  of  opium   .  .  .  .  0*01         ,, 

White  honey  q.s. 

To  make  one  pill 

These  pills  should  be  recently  prepared.  They  are 
very  efficacious.  Four  to  six  are  to  be  given  daily,  the 
number  being  steadily  diminished  as  the  stools  improve. 
Their  employment  should  be  discontinued  immediately 
appearances  of  stomatitis  set  in. 

Calomel  has  often  been  employed  alone  also,  the  daily 
dose  being  1  gramme  to  1  gramme  -20,  or  doses  of  30 
centigrammes  are  administered  every  six  or  eight  hours, 
or  fractional  doses  hourly.  The  doses  are  diminished 
and  the  intervals  between  them  increased  when  im- 
provement is  obtained.  Mercurial  stomatitis  is  of 
frequent  occurrence  after  such  treatment. 

Opium,  by  itself,  should  be  employed  with  reserve, 
and  only  as  a  temporary  remedy. 

Suppositories  of  cocaine  Qr  morphia  ease  the  tenesmus. 
Belladonna  calms  the  pains  without  producing  con- 
stipation, and  may  therefore  be  employed,  but  with 


330    DYSENTERY,  CHOLERA,  AND  TYPHUS 

prudence.  Kho-sam,  the  oleaginous  seeds  of  Brucea 
sumatrana,  is  said  to  cause  the  rapid  disappearance  of 
dysenteric  phenomena  (Mougeot,  Lemoine). 

4.  (b)  In  Cases  of  Chronic  Dysentery. — First  of  all  a 
purgative  should  be  given  (calomel  or  sulphate  of 
sodium). 

The  systematic  employment  of  Segond's  pills  or  of 
sulphate  of  sodium  (10  grammes  in  the  morning)  yields 
good  results.  It  is  necessary,  however,  to  supplement 
these  by  medicinal  enemata. 

Manson  recommends  a  brief  preliminary  treatment 
with  ipecacuanha,  preceding  the  administration  of 
castor  oil. 

To  produce  an  alternative  effect  on  the  ulcerated 
intestinal  surfaces,  local  dressings  have  been  proposed. 

Guido  Izar  examines  the  rectum  and  the  sigmoid 
colon  directly,  with  the  aid  of  an  instrument  con- 
structed by  Melocchi,  which  bears  the  name  of  the 
recto-sigmoidoscope,  and  which  is  a  happy  modification 
of  the  endoscope  of  Desormeaux.  He  then  applies 
dressings  directly  to  the  dysenteric  ulcerations,  paint- 
ing them  with  a  2  per  cent,  solution  of  permanganate 
of  potassium,  or  a  1  per  cent,  solution  of  nitrate  of 
silver,  or  oxygenated  water,  or  powdering  them  with 
dermatol,  or  a  mixture  of  charcoal  and  kaolin,  accord- 
ing to  Ascoli's  method.  It  is  manifest  that  this 
treatment  can  only  be  applied  to  ulcerations  con- 
fined to  the  lower  portion  of  the  large  intestine.  It 
cannot,  therefore,  be  employed  in  all  cases. 

Intestinal  irrigations  or  enemata  may  be  administered 
— a  solution  of  nitrate  of  silver,  0-5  per  1000,  boric  acid, 
20  per  1000  (Le  Dantec),  permanganate  of  potash,  0-5 
per  1000  (Gastinel),  Oxygenated  water  containing  ten 
times  its  volume  of  oxygen  diluted  with  five  times  its 
volume  of  tepid  sterilised  water  (Rocaz),  tincture  of 
iodine,  1  per  1000,  sulphate  of  copper,  aad  creosote,  1  or 
2  per  cent.  (Zanardini).  These  latter  are  toxic,  however, 
owing  to  absorption  in  the  region  of  the  ulcerations. 


TREATMENT  OF  DYSENTERY  331 

Le  Dantec  also  employs  what  he  calls  an  irrigation 
dressing,  always  preceded  by  a  cleansing  irrigation. 
He  employs  sub-nitrate  of  bismuth,  20  grammes  to  the 
dose,  the  bismuth  being  in  suspension  in  a  litre  of  tepid 
water  ;   or  else  the  following  mixture  : — 

Dermatol  ....  20  grammes 

Bicarbonate  of  soda   .  .  .  .  2        ,, 

Water  .....  1  litre 

The  most  effectual  disinfection  for  rapidly  accom- 
plishing the  destruction  of  the  amoebae  and  their  cysts 
is  obtained  by  the  following  enema  (H.  Vincent),  pre- 
ceded by  a  detergent  intestinal  irrigation  with  physio- 
logical water  (lukewarm)  ; — 

Labarraque's  Solution  .  .  10  to  12  grammes 

Nael    ......  5        ,, 

Distilled  water  ....        1000 

These  enemata  may  be  given  daily,  drop  by  drop 
(by  the  goutte  a  goutte  method),  without  pressure,  the 
patient  retaining  them  as  long  as  possible.  At  first, 
20  to  30  drops  of  tincture  of  opium  may  be  added. 

The  enema  should  be  given  warm  (98-4°  to  104°  F.), 
very  slowly,  with  the  long  rectal  tube,  the  patient  lying 
on  his  right  side. 

At  the  same  time  the  patient  is  given  6  to  10  grammes 
of  sulphate  of  soda  each  morning,  and  during  the  day  a 
draught  consisting  of : 

Syrup  of  ipecacuanha  .  .  .      5  to  6  grammes 

Extract  of  opium        .  .  .         0  "05  to  0*10        ,, 

Water  .  .  .  .  .  120        „ 

a  spoonful  being  given  every  two  hours,-  no  liquid 
nourishment  is  to  be  taken  within  thirty  minutes  of 
taking  the  dose. 

•  Warming  the  abdomen  by  means  of  the  electric 
apparatus  of  Laroquette  greatly  assuages  the  colics. 

The  preceding  treatments  sometimes  give  rapid 
recoveries  from  amoebic  dysentery. 


332  DYSENTERY,  CHOLERA,  AND  TYPHU8 

In  patients  suffering  from  chronic  dysenteries  of 
amoebic  origin,  who  frequently  suffer  from  malaria  as 
well,  the  physician  must  never  neglect  the  simultaneous 
administration  of  quinine,  preferably  by  subcutaneous 
injection.  Malarial  attacks,  even  when  slight  or 
attenuated,  very  often  cause  returns  of  amoebic 
dysentery  in  tropical  patients. 


PART  //.—THE  EPIDEMIOLOGY  AND 
PROPHYLAXIS    OF   DYSENTERY 

As  has  been  noted  in  the  foregoing  chapters,  dysentery 
is  a  syndrome  common  to  several  infections.  If  by 
dysentery  we  understand  the  contagious  process 
characterised  by  the  painful  and  repeated  emission  of 
bloody  and  mucous  stools,  determined  by  the  lodgment 
of  a  parasite  in  the  large  intestine  (and  sometimes  in 
a  portion  of  the  small  intestine),  we  must  include,  under 
this  heading  : 

1.  Bacillary  dysentery. 

2.  Amoebic  dysentery. 

3.  The  dysenteries  due  to  Balantidium  coli,  Tricho- 
monas intestinalis,  and  Schistosoma  mansoni ;  and, 
lastly,  other  forms  as  well,  of  a  more  exceptional  kind, 
such  as  the  dysenteries  due  to  spirilla,  to  Chilodon 
dentatus,  to  Leishmaniasis,  etc. 

The  etiological  conditions  which  govern  each  of  these 
dysenteries  are  subordinated  to  the  biological  char- 
acters of  their  pathogenic  germs,  their  degree  of  resist- 
ance in  the  external  environment,  and  the  degree  to 
which  desiccation,  the  oxygen  of  the  air,  light,  etc.,  are 
able  to  affect  them. 

All  these  dysenteries,  which  in  reality  differ  greatly 
from  one  another,  none  the  less  possess,  when  con- 
sidered from  the  epidemiological  standpoint,  a  number 
of  fundamental  characteristics  which  form  a  common 
link — namely,  the  fact  that  their  infectious  agent 
vegetates  in  the  lower  portions  of  the  alimentary  canal ; 
that  it  propagates  itself  in  the  mucous  membranes, 
the  glandular  tissue,  and  the  tunicae  of  the  intestine  ; 
that  it  provokes  ulcerative  lesions  there  ;  that  it  is 
eliminated   in   profuse   quantities   with   the   repeated 

333 


334   DYSENTERY,  CHOLERA,  AND  TYPHUS 

dejecta  of  the  patient ;  and,  finally,  that  the  pathogenic 
agent  residing  exclusively  or  principally  in  the  faeces 
always  constitutes,  whether  directly  or  indirectly,  the 
fundamental  agent  of  contagion. 

From  our  knowledge  of  the  plurality  of  dysenteries  it 
results  that,  when  considered  as  a  whole,  the  epidemio- 
logical rules  of  these  fundamentally  different  maladies 
none  the  less  offer  a  large  number  of  common  features. 
In  reality,  however,  there  are  two  of  these  various 
forms  of  dysentery  which,  owing  to  their  frequency  and 
their  gravity,  greatly  predominate  over  all  the  rest — 
namely,  bacillary  dysentery  and  amoebic  dysentery. 

These  two  affections,  then,  from  the  epidemiological 
point  of  view,  as  from  the  clinical  standpoint,  are  those 
which  should  more  particularly  receive  our  attention. 
We  shall  consider  them,  therefore,  in  succession. 


CHAPTER  IV 

EPIDEMIOLOGY  OF  BACILLARY  DYSENTERY 

Bacillary  dysentery  is  caused  by  a  special  bacillus 
seen  by  Chantemesse  and  Widal,  and  described  m  a 
specific  manner  by  Shiga,  then  by  Kruse,  Flexner, 
Strong  and  Musgrave,  Rosenthal,  etc.,  etc.,  and  finally 
by  L.  Rogers,  Vedder  and  Duval,  Dopter  and  Vaillard, 
etc.  It  constitutes,  in  reality,  one  species  of  syndrome 
resulting  from  different  races  of  the  same  microbe.  At 
least  four  groups  of  these  are  recognised  (see  Part  I.), 
excluding  the  pseudo-dysentery  bacilli,  which  react  in 
a  specific  manner  in  the  presence  of  sugars  and  form,  or 
do  not  form,  indol,  and  whose  other  biological  characters 
(agglutination,  bacteriolysis,  and  the  specific  action  of 
immunising  scrums)  are  more  or  less  distinct.  We 
have  already  discussed  these  groups. 

Bacillary  dysentery  is  a  ubiquitous  malady.  We  find 
it  in  all  countries,  in  all  climates,  but  it  is  especially 
a  malady  of  cold  or  temperate  countries.  In  this 
respect  it  is  unlike  amoebic  dysentery,  which  is  rnore 
common  in  hot  climates. 

On  the  other  hand,  each  epidemic  of  bacillary 
dysentery  seems  to  possess  its  own  variety  of  microbe 
(Shiga).  The  bacillus  of  the  type  discovered  by  Shiga 
was  isolated  in  Korea,  in  the  Japanese  army,  as  well 
as  in  Manchuria,  and  also  in  Russian  soldiers  at  Port 
Arthur  and  the  sailors  of  the  Baltic  squadron. 

At  the  time  of  the  Tokio  epidemic  this  original  bacillus 
was  extremely  rare,  and  the  bacilli  encountered  were 
those  of  the  other  races. 

In  the  Kobe  epidemic  of  1906  Amako  found  Shiga's 
bacillus,  or  its  varieties,  in  all  the  invaded  quarters. 

335 


336    DYSENTERY,  CHOLERA,  AND  TYPHUS 

At  the  end  of  the  epidemic  only  the  varieties  were 
found. 

Shiga's  bacillus  is  regarded  as  the  most  dangerous, 
but  Flexner's  may  give  rise  to  very  severe  forms  of 
dysentery. 

Epidemics  due  to  bacilli  of  the  Flexner  type  are 
common  in  the  Philippines,  the  United  States,  and 
Porto  Rico  ;  the  same  bacillus  is  found,  however,  in 
epidemics  in  Central  Europe,  France,  Tunisia  (Nicolle 
and  Cathoire),  Russia,  Algeria,  Morocco,  India,  etc. 

In  some  epidemics  bacilli  of  several  races  may  be  found 
(the  Shiga  type,  the  Flexner  type,  the  Y  type,  etc.).^ 

In  Delhi  dysentery  due  to  the  Y  bacillus  is  pre- 
dominant (Kurnen). 

In  Paris  the  bacilli  isolated  are  sometimes  of  the 
Shiga  type,  sometimes  of  the  Strong  or  Flexner  types. 

During  the  present  war  certain  epidemics  have  been 
reported  in  Galicia  and  Russian  Poland,  in  which 
bacteriological  examination  has  in  the  great  majority 
of  cases  failed  to  isolate  the  germ.  In  the  examination 
of  more  than  1000  stools  Shiga's  bacillus  was  isolated 
only- six  times,  Flexner's  twice,  and  the  Y  bacillus  once, 
nothing  being  found  in  the  other  cases. 

Generally  speaking,  bacillary  dysentery  is  prevalent 
everywhere  in  Europe,  but  more  particularly  in  the 
Mediterranean  basin  (Greece,  Turkey,  Italy,  Sicily, 
Spain,  Gibraltar,  and  Catalonia). 

Certain  countries,  as  the  north  of  Italy,  for  instance, 
are  sometimes  visited  by  serious  epidemics  of  bacillary 
dysentery.  Celli  has  described  the  epidemic  of  Belluno, 
where,  in  1894,  out  of  5700  inhabitants,  2564  were 
attacked.  Galli-Valerio  has  published  an  account  of 
the  epidemic  in  the  Valtellina  (1897),  in  which  the 
mortality  amounted  in  certain  localities  to  20  per 
cent,  of  those  attacked.  In  Switzerland  a  serious 
epidemic  visited  Leuk,  in  1893  ;  it  lasted  three  months, 
with  a  mortality  of  25  per  cent. 

^  Morgan's  type  was  also  found  in  cases  of  dysentery  at  the 
Dardanelles. — Ed. 


EPIDEMIOLOGY  OF  BACILLARY  DYSENTERY3d7 

Armand  Ruffer  and  Wilmer  have  mentioned  the 
serious  epidemics  of  bacillary  dysentery  which  occur 
among  pilgrims  who  have  returned  from  Mecca.  It  is 
estimated  that  in  the  vilayet  of  Hedjaz  this  malady 
causes  1000  to  15,000  deaths  annually. 

The  epidemics  of  dysentery  observed  in  our  armies 
at  the  front  during  the  present  war  against  Germany 
have,  as  a  rule,  revealed  the  bacillus  of  the  Flexner 
type,  more  rarely  the  Y  type  (Bonnel,  Joltrain,  and 
Taufflieb),  but  Shiga's  bacillus  has  also  been  isolated. 

Each  of  these  microbes  may  therefore  give  rise  to 
epidemic  patches,  more  or  less  distinct  and  of  greater 
or  less  extent,  which  may  run  into  one  another. 

German  writers  (Kruse  and  Doerr)  are  wrong  in 
attributing  epidemic  dysentery  to  Shiga's  type  alone 
(the  other  bacilli  being  said  to  give  rise  only  to  sporadic 
pseudo-dysenteries).  This  difterentiation  is  invalid. 
Neither  can  we  admit  the  existence  of  a  dysentery 
special  to  children  and  lunatics,  as  Kruse  would  have 
it.  As  a  matter  of  fact,  we  may  find  Shiga's  or  Flexner's 
bacillus  indifferently  (Auche). 

In  France  there  is  an  important  endemic  centre  in 
the  departments  of  Brittany,  where  certain  arrondis- 
sements  have  formerly  suffered  as  many  as  500  deaths. 
Dysentery  is  also  found  in  Champagne,  and  in  the 
Basse  Somme  and  in  the  eastern  division  of  France. 

The  official  statistics  published  by  the  Ministry  of 
the  Interior  do  not  give  figures  relating  to  the  precise 
frequency  of  dysentery  in  France,  as  the  disease  is  not 
subject  to  compulsory  notification. 

Dysentery  in  Armies 

The  sanitary  condition  of  the  army  is  in  general  in 
close  relation  to  that  of  the  civil  population.  The 
frequency  of  dysentery  in  military  circles  is,  therefore, 
in  accordance  with  the  epidemic  or  endemic  conditions 
of  the  garrison  towns.  It  is  important  to  note,  how- 
ever, that  the  soldier  is  particularly  vulnerable.    The 


338   DYSENTERY,  CHOLERA,  AND  TYPHUS 

statistics  of  the  French  Army  refer,  as  a  rule,  to  the 
sum  of  the  various  dysenteries  :  bacillary,  amoebic,  etc. 
It  may  be  affirmed,  however,  that  in  France,  in  time 
of  peace,  bacillary  dysentery  is  almost  the  only  form 
to  be  met  with,  excepting  a  few  imported  cases  of 
amoebic  dysentery,  the  subjects  being  colonial  soldiers. 
The  average  frequency  of  cases  hovers  about  1  per  1000, 
rather  below  this  figure  than  above  it.  The  region  of 
Lyons  is  that  most  affected.  Then  follow  the  18th 
Army  Corps  (Bordeaux),  the  13th  (Clermont-Ferrand), 
the  10th  (Reimes),  the  Military  Government  of  Paris, 
the  15th  Army  Corps  (Marseilles)  and  the  20th. 

The  Tunis  and  Oran  divisions  and  the  troops  in 
Morocco  reveal  a  morbidity  and  a  mortality  which  are 
uniformly  higher.  But  to  the  cases  properly  referable 
to  regional  influences  we  must  add  the  numerous  cases 
which  are  explained  by  the  fact  that  dysenteric  soldiers 
are  sent  home  from  Tonkin,  Madagascar,  Senegal,  etc.  : 
countries  in  which  dysentery  is  endemic. 

The  two  forms  of  dysentery,  bacillary  and  amoebic, 
are  found  to  co-exist  in  the  French  possessions  in 
North  Africa. 

The  statistical  records  of  the  French  Army  reveal 
rather  a  high  proportion  of  cases,  which  is  due  to  the 
fact  that  they  represent  the  total  number  of  cases 
reported  in  Tunis  and  Algeria  as  well  as  in  France. 

Of  all  armies  that  of  the  United  States  is  most 
subject  to  dysentery. 

In  the  French  Army  the  severest  forms  of  bacillary 
dysentery  are  observed,  as  a  rule,  among  the  troops  in 
Algeria  and  Tunis.  Certain  epidemics  (Hussein-Dey, 
1894)  have  been  extremely  formidable,  owing  to  the 
frequency  of  hypertoxic  forms  with  hypothermia  and 
a  rapidly  fatal  termination. 

At  intervals,  for  that  matter,  there  have  been 
epidemics  of  equal  gravity  in  France.  G.  Bertillon  has 
recorded  an  epidemic  which  broke  out  in  July,  1915, 
in  a  squadron  of  dragoons,  which  yielded  12  cases, 
of  which  5  were  of  an  extremely  grave  character. 


EPIDEMIOLOGY  OF  BACILLARY  DYSENTERY 3Sd 

Dysentery  shares  with  typhoid  fever  and  the  para- 
typhoid fevers  the  pecuHarity  of  attacking  armies  in 
the  field.  It  is,  however,  less  frequent  than  these.  It 
is  in  a  way  inseparable  from  the  medical  history  of 


Dysentery  in  the  World's  Armies 
Morbidity  per  1000  Men 


Army 

1903 

1904 

1905 

1906 

1907 

French 

2-34 

2-27 

1-66 

2-38 

108 

German 

0-17 

003 

0-10 

0-30 

0-01 

United  States 

37-71 

22-49 

16-93 

14-47 

British 

0-80 

0-60 

0-40 

0-40 

0-50 

Austrian     , 

0-50 

0^50 

0-60 

0-50 

0-40 

Bavarian     . 

0 

0 

0 

0-06 

0-02 

Belgian 

0-07 

0 

0 

0  03 

0-06 

Spanish 

0-27 

0-12 

0-07 

0-05 

0-10 

Italian 

0-30 

0-50 

Dutch 

0-10 

0 

Russian 

0-90 

0-50 

0-70 

0-90 

0-70 

Rumanian  . 

0-65 

0-90 

2-90 

0-60 

0-70 

warfare.  In  1415  the  English  Army,  which  had  in- 
vaded France,  became  the  prey  of  a  terrible  epidemic. 
After  the  battle  of  Agincourt  it  had  to  be  repatriated, 
having  lost  three-fourths  of  its  effectives. 

Pringle  has  recorded  the  epidemic  which  raged  through 
the  English  Army  in  July,  1743,  at  Dettingen  ;  half  the 
soldiers  were  attacked.  The  War  of  the  Polish 
Succession,  the  Austrian  War,  and  the  Seven  Years' 
War  were  marked  by  epidemics  no  less  deadly  in 
character. 

After  the  battle  of  Valmy  the  troops  of  the  Coalition 
carried  dysentery  into  Champagne.  The  Prussian 
Army,  reduced  to  half  its  effectives,  beat  a  retreat. 
At  the  time  of  the  wars  of  the  Revolution  and  the 
Empire,  Desgenettes  remarked  that  dysentery  had  very 
often  killed  more  men  than  the  fire  of  the  enemy.  In 
Egypt  Napoleon  lost  2468  men  from  dysentery. 


340    DYSENTERY,  CHOLERA,  AND  TYPHUS 

It  must  be  added  that  in  those  days  dysentery  was 
a  disease  of  extreme  gravity,  such  as  is  unknown  in  our 
time. 

At  the  beginning  of  the  conquest  of  Algeria  dysentery 
caused  as  many  deaths  as  malaria,  and  even  more 
(Kelsch). 

It  was  prevalent  during  the  Crimean  War.  Between 
May  and  September,  1855,  9000  cases  and  1478  deaths 
were  reported.  During  the  Italian  War  it  was  almost 
as  common  as  typhoid  and  malaria. 

The  War  of  Secession  shows  how  great  the  intensity 
of  this  malady  may  be  on  the  occasion  of  great  move- 
ments of  troops.  There  were  238,812  cases  of  acute 
and  25,670  of  chronic  dysentery  among  the  white  troops, 
with  4804  and  3229  deaths  respectively.  These  figures 
are  very  much  less  than  the  reality,  for  an  enormous 
number  of  cases  of  acute  diarrhoea  were  recorded 
(1,155,226),  in  addition  to  chronic  cases  (170,488), 
which  altogether  caused  30,481  deaths. 

We  shall  see  later  that  diarrhoea  is  very  often  only 
the  abnormal  or  attenuated  expression  of  dysenteric 
infection. 

The  German  Army  was  much  harassed  by  dysentery 
during  the  war  of  1870-1871.  There  were  35,652  cases 
and  2380  deaths  due  to  this  malady.  The  troops  be- 
siegmg  Metz  had  an  enormous  proportion  of  cases. 

The  Russo -Turkish  War  afforded  another  proof  of 
the  intensity  of  this  disease  in  time  of  war.  Cases  of 
diarrhoea  were  extremely  numerous,  very  few  men 
escaping  it.  The  statistics  record,  for  the  army  of  the 
Danube,  34,198  cases  (5775  per  1000)  of  dysentery, 
and  9543  deaths  (1611  per  1000).  The  army  of  the 
Caucasus,  much  weaker  in  numbers,  was  visited  even 
more  severely  :  22,084  cases  (90  per  1000)  and  3552 
deaths  (15  per  1000). 

During  the  short  Bosnian  Campaign  the  deaths  from 
dysentery  for  a  total  effective  of  198,000  men  were  324. 

During  the  Tunis  Expedition  among  20,000  men  there 
were  3954  cases  and  83  deaths  from  the  same  disease. 


EPIDEMIOLOGY  OF  BACILLARY  DYSENTERY24:1 

At  the  time  of  the  Chino -Japanese  War  dysentery- 
appeared  as  soon  as  the  Japanese  Army  disembarked  in 
Korea.  Although  the  season  was  winter,  the  hospitals 
were  overflowing  wdth  cases  of  dysentery.  There  were 
12,052  cases  among  200,000  men. 

The  French  Expeditionary  Corps  sent  to  China  at  the 
time  of  the  Allied  Expedition  in  1900  had  818  cases  and 
52  deaths.  The  American  troops  (1947  men)  had  353 
cases  in  two  months. 

Among  the  British  troops  sent  to  South  Africa  at  the 
time  of  the  Boer  War  there  were  more  than  2500  cases 
of  dysentery. 

During  the  Russo-Japanese  War  the  Russians  had 
6140  cases  and  the  Japanese  6624  cases. 

The  Morocco  Expeditionary  Corps  had  1080  cases 
of  dysentery  (amoebic)  in  1912,  and  1295  in  1913  (Job). 

The  war  of  1914  has  been  no  exception  to  the  rule. 
Dysentery  made  its  appearance  among  the  soldiers  of 
the  French  Army  after  the  battle  of  the  Marne.  Since 
then  it  has  been  encountered  continually  in  the  various 
armies  at  the  front,  in  France,  at  the  Dardanelles,  and 
at  Salonika,  sometimes  appearing  in  grave  and  deadly 
forms,  but  more  often  in  benign  forms  which  lead  to 
a  prompt  recovery. 

Remlinger  has  reported  this  malady  among  the  French 
troops  in  the  Argonne.  He  isolated  an  atypical  and  not 
very  toxic  bacillus.  L.  Tribondeau  and  Fichet  have 
published  the  results  of  their  investigations  as  regards 
dysentery  at  the  Dardanelles.  The  bacillus  most 
frequently  isolated  was  that  of  Shiga's  type  (23  times  out 
of  38)  ;  the  Y  bacillus  w^as  found  twice,  and  the  bacillus 
of  Morgan's  type  13  times. 

In  1915  a  serious  epidemic  of  dysentery  appeared 
among  the  German  armies  in  Galicia.  The  death-rate 
amounted  to  16  per  cent,  of  those  attacked. 

During  all  the  epidemics  which  have  appeared  in 
France,  in  the  civil  population  as  w^ell  as  in  the  armies, 
physicians  have  drawn  attention  to  the  frequency, 
sometimes  excessive,  of  concomitant  diarrhoea.     At  the 


342    DYSENTERY,  CHOLERA,  AND  TYPHUS 

time  of  the  epidemic  which  broke  out  at  Versailles  in 
1902,  in  the  1st  and  5th  Regiments  of  Engineers,  a 
fourth  of  the  patients  suffered  from  simple  diarrhoea. 
It  was  the  same  in  1903  in  the  case  of  the  3rd  Battalion 
of  Chasseurs  at  Grenoble. 

When  the  agglutinative  reaction  is  sought  for  in  such 
cases  of  simple  diarrhoea,  it  is  commonly  found  to  be 
positive.  Job,  Braun,  and  Roussel  have  often  verified 
this  fact. 

During  the  present  war  against  Germany  all  physicians 
have  noted  the  frequency  of  these  diarrhoeas,  which, 
bacteriologically  speaking,  may  be  laid  to  the  account 
of  the  dysentery  bacillus  (Sacquepee,  Burnet,  and 
Weissenbach). 

Consequently,  in  addition  to  confirmed  cases  of 
dysentery,  we  must  reckon  with  ill-defined  or  attenu- 
ated forms.  From  the  epidemiological  standpoint 
these  are  extremely  important,  as  they  lend  themselves 
with  great  facility  to  the  propagation  of  the  disease  by 
reason  of  the  fact  that,  being  apparently  of  little  im- 
portance, they  do  not  seem  to  necessitate  any  special 
precautions. 

The  chronic  forms  of  bacillary  dysentery,  and  the 
diarrhoea  of  children,  which  may  also  contain  the  bacillus 
in  great  profusion  (Flexner  and  Strong,  Vedder  and 
Duval),  are  subject  to  the  same  remarks.  Duval  and 
Basset,  during  an  epidemic,  examined  the  stools  of 
forty-two  patients  suffering  from  simple  diarrhoea,  and 
found  the  dysentery  bacillus  in  them.  Shiga  has 
reported  a  similar  experience. 

Of  course,  all  cases  of  diarrhoea  observed  in  the  armies 
in  the  field  are  not  due  to  the  dysentery  bacillus.  Many 
are  due  to  infection  by  the  enterococcus  of  Thiercelin, 
to  the  Proteus  vulgaris,  or  to  the  polymicrobian  vegeta- 
tion which  readily  attains  an  unrestrained  development 
in  the  case  of  overworked  men.  But  the  dysentery 
bacillus  is  incontestably  responsil:>le  for  a  great  number 
of  those  cases  of  common  diarrhoea  which  are  always 
encountered  side  by  side  with  the  classic  dysenteries. 


CHAPTER  V 

ETIOLOGY 

The  Predisposing  Causes  of  Bacillary  Dysentery 

Bacillary  dysentery  exists  in  all  countries  and  all 
climates,  but,  as  we  have  already  remarked,  it  is  most 
commonly  met  with  in  cold  and  temperate  countries. 

When  it  appears  in  cold  countries  it  gives  rise  with 
moderate  frequency  to  serious  epidemic  manifestations. 
Sweden,  Norway,  the  northern  regions  of  Russia,  Kam- 
chatka, and  Denmark  have  all  been  visited  by  epidemics, 
some  of  these  being  of  great  severity. 

But  the  influence  of  cold  climates  is  by  no  means 
absolute.  Here  is  the  proof  :  if  we  examine  the  curve 
of  endemicity  among  the  civil  population  or  in  the  army 
in  temperate  climates,  we  find  that  it  reaches  its 
maximum,  more  often  than  not,  during  the  hot  season 
— that  is,  in  the  summer,  and,  above  all,  in  the  autumn. 

During  great  wars,  and  notably  during  the  present 
war,  dysentery  has  evaded  the  influence  of  the  hot 
season  and  has  been  prolonged  into  the  winter.  During 
the  Crimean  War  the  French  trenches  were  full  of  men 
sick  of  dysentery  during  the  coldest  months  of  the  year. 

It  was  the  same  during  the  War  of  Secession.  The 
months  of  November  and  December,  1862,  were  marked 
by  a  great  recrudescence  of  dysentery. 

Exposure  to  cold  by  day,  and  above  all  by  night, 
under  canvas  and  in  the  trenches,  abdominal  chills, 
and  the  effects  of  rain,  which  soaks  men's  clothes 
(Cambay),  and  the  fording  of  rivers,  which  has  the  same 
result,  have  been  invoked  as  predisposing  causes. 

Individual  predisposing  causes  deserve  mention. 
All  ages  are  susceptible  ;   nevertheless  children  seem  to 

343 


344  DYSENTERIC  CHOLERA,  AND  TYPHUS 

be  more  often  attacked  in  countries  where  the  disease 
is  endemic,  as  well  as  young  people  who  have  recently 
arrived  in  the  country.  This  is  often  seen  to  be  the 
case  with  young  soldiers. 

Neither  are  there  any  races  which  are  refractory  to 
this  form  of  dysentery.  It  is  as  prevalent  in  the  northern 
regions  as  in  the  south  of  Europe.  The  yellow  race 
is  as  frequently  attacked  as  the  white  race,  nor  does  the 
black  race  escape. 

Domestic  animals,  such  as  the  dog,  may  contract 
bacillary  dysentery,  as  has  been  proved  by  bacterio- 
logical examinations. 

The  predisposing  influence  of  extreme  fatigue,  and  of 
over-exertion,  has  justly  been  incriminated.  Wars 
realise  these  conditions  in  the  highest  degree.  It  is  the 
same  with  physiological  poverty,  a  defective  diet,  coarse 
and  indigestible  food,  the  abuse  of  biscuits,  etc.  During 
the  Balkan  War  the  Russian  doctors  laid  stress  upon 
these  different  causes,  notably  the  consumption  of  de- 
composing bread,  putrefying  food-stuffs,  and  impure 
water.  To  these  one  must  add  the  inhalation  of  un- 
wholesome emanations  (from  latrines,  cess-pits,  de- 
composing corpses,  etc.),  which  cause,  as  in  the  diarrhoea 
of  the  operating  theatre,  an  irritation  of  the  mucous 
lining  of  the  intestines,  a  hypersecretion  of  bile,  and 
an  eliminating  diarrhoea  ;  this  irritation  prepares  the 
ground  for  specific  infection  by  the  dysentery  bacillus. 

The  protective  effect  of  a  previous  infection  is  of 
great  importance.  It  is  well  established  that  a  first 
attack  of  bacillary  dysentery  confers  substantial  im- 
munity, and  this  explains  why,  in  countries  where 
dysentery  is  endemic,  it  more  particularly  afflicts 
children,  young  soldiers,  and  new-comers,  as,  for  that 
matter,  does  typhoid  fever.  This  immunity  is  highly 
effectual,  for  out  of  1000  individuals  who  had  previously 
suffered  from  bacillary  dysentery,  only  3  or  4  were 
susceptible  of  contracting  it  again  (Shiga),  even  when 
the  previous  attack  had  been  extremely  benign.  This 
explains  why  an  epidemic  rarely  attacks    the    same 


CAUSES  OF  BACILLARY  DYSENTERY       345 

population  two  years  in  succession.  The  usual  interval 
between  the  great  epidemics  of  bacillary  dysentery  is 
ten  to  twenty  years  in  the  same  locality.  During  this 
interval  there  has  been  time  for  a  fresh  generation  of 
receptive  subjects  to  spring  up. 

The  army,  on  the  other  hand,  offers  a  continuous  re- 
ceptivity, because  it  constitutes  a  collectivity  which  in 
time  of  peace  is  renewed  every  two  or  three  years ;  to 
it  every  soldier  who  has  recently  joined  the  ranks 
brings  fresh  aliment  for  an  infection  against  which  he 
has  not  been  rendered  immune. 

The  Determining  Causes  of  Bacillary  Dysentery 

The  bacillus  of  dysentery  may  show  itself  in  healthy 
organisms,  unaffected  by  fatigue,  or  by  conditions  of  diet, 
or  other  factors.  The  different  circumstances  already 
enumerated  are,  therefore,  in  reality,  only  accessories 
of  the  infecting  germ,  which  is  the  sole  determining 
cause  of  the  malady. 

Having  found  its  way  into  the  alimentary  canal,  the 
bacillus  proceeds  to  localise  itself  by  election  in  the 
mucous  membrane  of  the  large  intestine,  and  also  in  a 
portion  of  the  small  intestine,  where  it  provokes  the 
lesions  which  are  special  to  the  malady.  The  sub- 
cutaneous or  intravenous  inoculation  of  the  bacillus 
into  rabbits,  dogs,  and  cats,  etc.,  results  in  symptoms 
and  lesions  identical  with  those  observed  in  man. 

The  dysentery  bacillus  lives  exclusively  in  the  intestine 
of  the  patient.  1  It  is  not  found  elsewhere  (if  we  ex- 
cept the  bile).  It  exists  in  the  stools  in  considerable 
quantities.  The  stools,  therefore,  are  the  essential  and 
exclusive  element  of  dysenteric  contagion. 

The  most  usual  mode  of  contagion  is  by  way  of  the 
mouth.  Strong  and  Musgrave  caused  an  Indian  con- 
demned to  death  to  swallow  a  solution  of  bicarbonate 
of  soda,  and  then  a  culture  of  bacilli  two  days'  old. 

^  Rosenthal,  however,  has  isolated  the  bacillus  from  the  blood  of  the 
heart  at  autopsy. 


346    DYSENTEBY,,  CHOLERA,  AND  TYPHU8 

After  thirty-six  hours  diarrhoeal  and  mucous  evacua- 
tions appeared,  streaked  with  blood  ;  their  expulsion 
was  very  frequent  (as  many  as  31  stools  in  twenty- 
four  hours),  and  there  was  meteorism,  with  abdominal 
pains. 

Cases  of  accidental  infection  by  the  absorption  of 
cultures  (Flexner)  have  been  reported.  Dodge  has 
recorded  the  case  of  a  laboratory  assistant  who,  at  the 
end  of  twenty-four  hours,  was  attacked  by  an  acute 
dysentery,  a  small  quantity  of  a  culture  having  flown 
into  his  eyes  while  he  was  handling  a  broken  tube. 

It  is  easy  to  understand  that  the  frequency  of 
evacuations,  and  the  abundance  at  all  stages,  and 
especially  at  the  outset,  of  the  dysentery  bacillujs  in 
these  evacuations,  greatly  favour  the  spread  of  the 
contagion  by  the  dysentery  patient. 

This  is  why  direct  contagion  is  very  common.  Hence 
epidemics  in  the  family,  the  household,  or  the  village 
may  follow  the  arrival  of  a  single  sufferer.  The  epi- 
demic spreads  like  a  spot  of  oil,  successively  reaching 
those  about  the  patient,  his  relatives,  the  servants,  and 
the  neighbours.  In  country  districts  especially  con- 
tagion is  easily  effected,  as  the  inhabitants,  being 
ignorant  of  the  elementary  principles  of  hygiene, 
unconsciously  expose  themselves  to  the  danger  of 
contagion. 

Transmission  is  effected  directly  by  the  hands  (from 
the  hand  of  the  patient  to  the  hand  of  the  receptive 
subject),  the  hands  being  contaminated  by  the  dejecta, 
through  handling  bedroom  utensils  or  slop-pails,  body- 
linen,  sheets,  etc.  From  this  moment  many  circum- 
stances may  enable  the  bacillus  to  obtain  access  to  the 
mouth  of  the  healthy  subject. 

In  hospitals  direct  contagion  often  results  in  attacks 
on  nurses  and  students  who  attend  upon  dysentery 
patients,  and  also  on  adjacent  inmates. 

Inter-human  contagion  operates  in  the  same  way  in 
camps,  during  manoeuvres,  and,  lastly,  in  time  of  war, 
and  the  transport  of  the  germ  is  due  to  the  same 


CAUSES  OF  BACILLARY  DYSENTERY      347 

mechanism,  more  particularly  to  dirty  hands.  The 
appearance  of  dysentery  in  a  cook,  or  a  canteen-keeper, 
or  his  assistants,  is  genuinely  dangerous  in  this  respect, 
as  direct  contagion  is  then  augmented  by  other  modes 
of  contagion,  through  a  great  variety  of  intermediate 
agencies. 

Hence  it  is  that  the  dysentery  bacillus  is  so  readily 
disseminated  by  the  dejecta  of  patients,  by  dead  bodies, 
and  by  anything  that  has  become  contaminated — water, 
the  soil,  etc. 

The  dog,  being  susceptible  to  bacillary  dysentery,  is 
also  able  to  communicate  the  disease  to  man. 

Bacillary  dysentery  is,  therefore,  one  of  the  most  con- 
tagious of  diseases. 

Whatever  may  be  the  mode  of  contagion,  whether 
direct  or  indirect,  the  point  of  departure  of  the  bacillus 
is  always  to  be  found  in  the  faecal  matter  of  the  patient 
or  the  carrier.  The  dysenteric  patient  is  contagious 
from  the  onset  of  the  disease,  from  the  appearance  of 
the  very  first  symptoms,  although  these  may  appear 
harmless  :    such,  for  example,  as  diarrhoea. 

The  period  of  incubation  in  bacillary  dysentery  is 
on  an  average  from  two  to  five  days,  sometimes  a  week. 
The  bacilli  are  particularly  numerous  in  the  stools 
during  the  initial  period. 

The  disease  is  contagious  during  the  whole  of  its 
course,  and  it  very  commonly  remains  contagious  dur- 
ing convalescence  also.  There  are  many  examples  to 
prove  the  role  of  the  convalescent  in  spreading  the 
germ.  Moreover,  relapses  are  sometimes  observed 
several  weeks  after  recovery  (Shiga).  In  such  cases, 
therefore,  the  bacillus  had  not  disappeared.  In  1900 
a  French  soldier,  convalescent  from  bacillary  dysentery, 
was  the  cause,  at  Vallorbe,  by  direct  or  indirect  con- 
tagion, of  twelve  cases,  with  four  deaths.  Bacterio- 
logical tests  enable  one  to  find  bacilli  in  the  stools  after 
the  patients  have  recovered  from  the  disease. 

Thus  there  are  carriers  of  bacillary  dysentery,  capable 
of    disseminating   the   dysentery   bacillus    with   their 


348  DYSENTERY,  CHOLERA,  AND  TYPHUS 

excreta,  just  as  there  are  carriers  of  typhoid  and 
para-typhoid  fever. 

Bacteriological  researches  show  that  in  some  subjects 
the  persistence  of  the  bacillus  may  continue  for  three  or 
four  weeks,  for  a  few  months,  or  even  for  a  year  or  more. 
The  proportion  of  these  carriers  of  germs,  temporary  or 
otherwise,  is  5  to  7  per  cent. 

It  should  be  noted  that  with  certain  of  these  carriers 
the  persistence  of  the  bacillus  is  at  the  same  time  be- 
trayed by  a  chronic  diarrhoea  of  a  dysenteric  nature 
(H.  Vincent),  which  may  continue  for  one  or  two  years. 
These  subjects  are  extremely  active  propagators  of  the 
virus.  It  is  therefore  important  to  pay  attention  to 
these  refractory  diarrhoeas,  which  do  not  always  com- 
mence with  the  clinical  signs  of  dysentery,  with  its 
mucous  and  blood-stained  dejecta. 

The  existence  of  germ-carriers  who  have  never  pre- 
sented (or  do  not  appear  to  have  presented)  symptoms 
of  dysentery,  or  even  of  diarrhoea  (Duval,  Jehle,  and 
Charleton),  has  been  verified.  These  carriers  have 
accordingly  to  be  ferreted  out,  and  it  will  readily  be 
understood  how  dangerous  they  are  when  they  follow 
callings  which  entail  the  handling  of  food,  such  as  those  of 
cook,  butcher,  milkman,  pastrycook,  waiter,  etc. 

Children  are  frequently  disseminators  of  dysentery. 

The  prolonged  persistence  of  the  dysentery  bacillus 
in  certain  subjects,  sick  or  healthy,  explains  the  main- 
tenance of  the  endemic  condition  in  certain  countries, 
and  the  appearance  of  unexplained  cases  in  a  village,  a 
house,  or  a  family.  Carriers  of  germs,  moreover,  suffer 
from  time  to  time  from  attacks  of  diarrhoea,  with 
the  passage  of  abundant  stools,  which  maintain  the 
contagion. 

There  are,  therefore,  great  epidemiological  analogies 
between  dysentery  and  typhoid  fever,  the  para-typhoid 
fevers,  and  cholera. 

The  bacillus  occurs  in  the  gall-bladder  of  some 
individuals,  but  not  in  all  (H.  Vincent).  If  an  active 
culture    of    Flexner's    bacillus    is    injected   into   the 


CAUSES  OF  BACILLARY  DYSENTERY       349 

veins  of  a  rabbit,  or  under  the  skin,  or  into  the  peri- 
toneum of  the  guinea-pig,  the  bacillus  is  not  always 
found  in  the  gall-bladder,  even  when  the  animal  pre- 
sents the  characteristic  lesions  in  the  intestine.  If  the 
animal  is  killed  at  various  stages  (from  eighteen  hours 
to  ten  days)  the  bacilli  may  be  found  in  the  gall-bladder 
(on  one  occasion  it  was  found  after  twenty-eight  hours), 
but  this  is  very  exceptional.  The  urine  never  shows  it, 
but  it  may  be  isolated  from  the  spleen  and  the  liver. 
As  a  rule  it  is  found  in  the  bile  only  when  the  bacilli 
have  been  injected  into  the  peritoneum. 

In  man  it  has  been  isolated  from  the  mensenteric 
glands  (H.  Vincent). 

Amako,  having  made  a  bacteriological  examination 
of  the  bile  and  the  splenic  secretion  of  sixteen  indi- 
viduals who  had  died  of  dysentery,  v^as  unable  to 
isolate  the  bacillus. 

Further,  if  the  bacillus  of  Shiga  or  Flexner  is 
cultivated,  in  sterilised  bile,  human  or  animal,  this 
medium  is  highly  unfavourable.  The  bacillus  does  not 
propagate  itself,  but  generally  dies  out  after  a  few  days 
(H.  Vincent). 

Although  the  bacillus  has  sometimes  been  isolated 
from  the  human  gall-bladder  at  autopsies,  there  are 
certain  unknown  details  which  have  yet  to  be  cleared  up. 
Does  the  bacillus  form  colonies  exclusively  in  the  gall- 
bladder, and  if  so,  under  what  circumstances  ?  May  it 
not  remain  and  subsist  in  the  intestinal  glands,  these 
becoming  the  point  of  departure  in  the  attacks  of 
diarrhoea  of  which  we  have  spoken  ? 

Indirect  Contagion     • 

To  the  modes  of  propagation  by  contact  must  be 
added  those  by  indirect  transmission,  which  also, 
plays  an  important  part  in  the  dissemination  of  the 
disease. 

Transmission  by  all  kinds  of  intermediate  agents 
is  feasible  because  the  dysentery  bacillus  is  able  to 


350    DYSENTERY,  CHOLERA,  AND  TYPHUS 

survive  outside  the  human  organism  for  a  varying 
length  of  time. 

EUminated  with  the  faeces,  the  bacilhis  finds  its 
way  into  the  soil,  into  latrines,  into  water-supplies, 
and  contaminates  linen,  food,  etc.  It  is  often  trans- 
ported by  the  patient  himself,  who,  if  he  is  suffering 
from  a  benign  form  of  the  disease,  moves  from  place 
to  place  disseminating  the  germ.  The  most  recent 
cases  are  the  most  dangerous,  especially  in  compact 
bodies,  such  as  regiments,  schools,  factories,  etc.  It  is 
the  earliest  stage  which  corresponds  with  the  most 
profuse  elimination  of  the  bacilli  in  the  stools.  When 
the  disease  has  continued  for  some  days,  the  bacilli 
become  rarer. 

Disseminated  in  an  external  medium,  the  bacilli  are 
not  immediately  destroyed.  Their  vitality  varies  con- 
siderably. The  bacilli  of  Flexner's  type  seem  best 
adapted  to  survival  outside  the  human  body.  Those  of 
Shiga's  type  are  far  more  delicate  and  frail. 

In  general,  the  dysentery  bacillus  survives  longer 
and  more  readily  in  cool  and  damp  surroundings.  This 
is  exemplified  in  the  following  data. 

Vitality  of  dysentery  bacilli : 


Damp  earth,  sterilised 

Dry  earth      .  .  .  . 

Garden  soil  (surface) 

Garden  soil  at  a  depth  of  12  inches 

Soil  from  a  heath 

Dry  sand  (surface)    . 

Damp  sand  at  a  depth  of  12  inches 

Dried  cultures 

Cultures  in  bouillon 

Cultures  on  agar 

Dejecta  buried*in  the  soil     . 

Dejecta  on  linen  (folded  up) 


13  to  34  days 

6„  15 

6  „  15 
34  ,,  49 
20  ,,  31 

3  ,,     4 

29  „  39 
5  „     7 

20  ,,  25 
25  „  30 

30  ,,  90 
more  than  30 


Similar  investigations  have  been  made  in  respect 
to  water,  exposed  to  the  action  of  light  or  in  darkness, 
and  under  conditions  of  greater  or  less  contamination. 

A  culture  of  Shiga's  bacillus  was  emulsified  in 
water  drawn  from  the  River  Vanne  and  sterilised.     A 


CAUSES  OF  BACILLARY  DYSENTERY     351 

successive  series  of  cultures  gave  the  following  results 
(H.  Vincent) :— 


At  the  outset 

94,000  baci 

After    8  hours 

77,000      „ 

„      24    „ 

30,000      „ 

„      31     „ 

29,500      „ 

„      48     „ 

13,000      „ 

»      72    „ 

2,000      „ 

,,        4  days 

850      „ 

,,        5     „ 

120      „ 

„       6    „ 

2  to  14      „ 

Hi  per  CO. 


This  shows  that  the  disappearance  in  water  is 
suddenly  accelerated  after  the  second  or  third  day. 

In  impure  water  the  vitality  of  the  bacillus  does 
not  persist  nearly  so  long.  In  impure  sterilised  water 
the  bacillus  disappears  in  ten  to  twelve  days  at  14°  to 
16°  C,  and  in  thirteen  days  at  1°  to  4°  C.  In  water 
drawn  from  the  Vanne,  which  contained  220  germs  per 
cc,  the  bacillus  persisted  for  nine  to  eleven  days  at  a 
temperature  of  15°  to  18°  C.  In  very  impure  \^ater  it 
survives  only  two  to  five  days  at  22°  to  28°  C. 

If  these  experiments  are  made  with  samples  of  waters 
unequally  contaminated  by  saprophytic  organisms,  and 
kept  at  a  temperature  of  from  2°  to  4°  C,  in  order 
to  prevent  the  excessive  multiplication  of  saprophytes, 
we  find  that  the  bacillus  lives  only  two  to  four  days, 
and  that  its  disappearance  takes  place  sooner  when  the 
water  contains  a  larger  number  of  common  bacteria. 
These  latter  are  antagonistic  to  the  pathogenic  bacillus. 
The  Staphylococcus  pyogenes,  th,e  Micrococcus  prodigiosus, 
the  Bacillus  coli,  the  Bacillus  fluorescens  liquefadens, 
the  Proteus  vulgaris,  the  anaerobic  microbes  living  in 
water,  and  the  germs  of  putrefaction,  are  more  especi- 
ally hostile  in  their  action  upon  the  dysentery  bacillus. 
Even  the  filtrate  of  these  mici'obes  possesses  a  deterrent 
action  (H.  Vincent). 

In  ice,  and  in  darkness,  the  bacillus  has  been  found 
to  survive  for  forty-one  to  sixty-eight  days. 

The   action    of    sunlight    is   very   important.     The 


352    DYSENTERY,  CHOLERA,  AND  TYPHUS 

bacillus  behaves  differently,  accordingly  as  it  exists  in 
a  subterranean  body  of  water,  sheltered  from  the  rays 
of  the  sun,  or  in  the  water  of  a  river  or  a  lake,  etc., 
where  the  rays  of  the  sun  can  exert  their  powerful 
microbicidal  action. 

In  clear  water  direct  sunlight  destroys  the  bacillus 
in  two  to  two  and  a  half  hours.  If  the  emulsion  is  rich, 
so  that  the  water  is  turbid,  the  bacillus  survives  for  four 
or  five  hours. 

In  the  diffused  light  of  tlie  laboratory  it  dies  in  eight 
days,  while  in  darkness  it  lives  for  fourteen  days. 

Cold,*  humidity,  and  darkness  are  therefore  important 
factors  of  preservation  as  regards  the  bacillus  of 
dysentery.  Heat,  desiccation,  and  sunlight,  together 
with  the  vital  competition  of  saprophytes,  are,  on 
the  contrary,  the  most  effectual  natural  means  of  its 
destruction. 

All  these  facts  find  their  application  in  the  epidemi- 
ology of  bacillary  dysentery ;  they  explain  the  frequency 
of  the  malady,  and  its  persistence  in  cold  climates,  the 
real  though  limited  role  of  water,  the  preservation  of 
the  germ  in  the  soil  under  certain  conditions,  etc. 

The  receptacles  of  the  dysentery  bacillus  are,  as  we 
have  said,  very  numerous.  Latrines,  privies,  etc.,  often 
serve  as  the  connecting  link  between  the  sick  man  and 
the  healthy  subject,  infection  occurring  through  the 
medium  of  boots  or  shoes,  which  carry  the  germ  into 
the  house,  the  kitchen,  and  the  dining-room  or  mess- 
room,  where  it  lies  on  the  floor.  Finally,  the  hands  may 
pick  up  the  bacillus. 

In  armies,  in  time  of  peace,  and  above  all  in  time  of 
war,  the  cesspits  are  too  often  rendered  unapproach- 
able by  sloughs  of  filth  in  which  mud  and  fgecal  matter 
are  mingled,  and  which  serve  as  reservoirs  for  the  germs. 
After  such  a  microbic  foot-bath  a  man  carries  the 
bacillus  with  him  wherever  he  goes. 

Hence  we  understand  why  a  first  case  of  dysentery 
may  be  followed  swiftly  by  an  epidemic  outbreak,  and 
there  are  many  examples  of  regiments  which  have 


CAUSES  OF  BACILLARY  DYSENTERY       353 

occupied  barracks,  camps,  or  cantonments  previously 
inhabited  by  men  afflicted  with  dysentery,  which  have 
in  their  turn  contracted  epidemics,  sometimes  of  a 
formidable  nature. 

The  soil  has  the  power  of  preserving  the  bacillus 
intact,  especially  in  winter  and  during  the  rainy  season. 
In  1890  some  troops  proceeded  to  install  themselves  in 
the  camp  of  Chalons,  and  dug  the  emplacements  for  their 
tents  in  ground  where  old  cesspits  full  of  faecal  matter 
were  uncovered.  Dysentery  had  prevailed  there  the 
year  before.  These  men  contracted  dysentery  ;  the 
rest  of  the  troops  were  unaffected.  Does  this  explain 
why,  almost  every  year,  at  a  given  date,  we  see  dysentery 
reappearing  with  disheartening  persistence  in  certain 
garrisons — such  as  Vincennes  and  Versailles — and  in 
certain  camps — such  as  Chalons  ?  As  we  shall  see 
farther  on,  flies  also  play  a  part  in  this  periodic  return 
of  epidemics. 

In  country  districts  the  contamination  of  the  soil 
may  contribute  in  the  same  way,  in  addition  to  direct 
contagion,  to  the  maintenance  of  epidemic  or  endemic 
dysentery. 

It  seems  established  that,  notwithstanding  the  rather 
limited  vitality  of  the  dried  bacillus,  the  admixture 
of  the  bacillus  with  dust  is  capable  of  propagating 
dysentery  by  inhalation.  In  1894  a  battery  of  artillery 
was  sent  to  occupy  the  camp  of  Hussein-Dey,  near 
Algiers.  In  the  preceding  year  there  had  been  an 
epidemic  of  dysentery  in  this  camp.  After  a  very 
violent  gale,  which  raised  whirlwinds  of  dust  and  sand, 
and  which  lasted  a  week,  the  men  complained  that  every- 
thing they  ate  and  drank  was  full  of  earth  and  sand. 
A  very  serious  epidemic  followed,  affecting  15  per  cent, 
of  their  effectives.  Their  drinking-water,  vegetables, 
and  other  rations  were  wholesome. 

During  the  war  in  the  Transvaal  the  English 
physicians  attributed  the  epidemic  state  of  dysentery 
not  to  the  water,  but  to  dried  faecal  matter,  and  the 
sandstorms  occurring  on  the  veldt.     There  is  no  need 


354    DYSENTERY,  CHOLERA,  AND  TYPHUS 

to  demonstrate  the  danger  of  spreading  faecal  matter 
on  the  soil,  and  of  allowing  vegetable  crops  or  surface 
waters  to  become  contaminated  with  it.  The  cultiva- 
tion of  vegetables  in  market  gardens  by  means  of  this 
barbarous  method  of  manuring  exposes  large  numbers 
of  persons  to  the  danger  of  infection. 

Cases  of  contagion  by  means  of  clothing  worn  by 
patients,  their  underclothing,  sheets,  shirts,  etc.,  have 
been  reported.  The  washerwoman's  calling  exposes 
her  in  a  special  manner  to  contagion. 

In  camps  and  cantonments  soiled  bedding-straw  may 
be  a  factor  of  contamination. 

Contaminated  food- stuffs  also  play  a  by  no  means 
negligible  part  in  the  transmission  of  the  disease,  whether 
they  have  been  handled  by  persons  suffering  from  acute 
or  chronic  dysentery,  or  have  been  in  contact  with  soil 
impregnated  with  faecal  matter  (as  may  be  the  case 
with  vegetables  and  fallen  fruits),  or  have  had  the  germs 
deposited  upon  them  by  flies. 

The  contamination  effected  by  persons  suffering  from 
dysentery,  or  by  carriers  of  the  germ,  is  usually  due  to 
unclean  hands,  the  patient  or  carrier  having  neglected 
to  wash  them  after  visiting  the  closet  or  privy.  The 
bacillus  survives  for  thirty  days  on  bread,  rice,  cooked 
meat,  etc. 

In  addition  to  direct  contagion,  it  is  an  undoubted 
fact  that  flies  (Mvsca  domestica,  Calliphora  vomitoria, 
Lucilia  ccesar),  which  carry  a  large  number  of  infectious 
agents,  play  a  very  important  part  in  the  propagation  of 
hacillary  dysentery.  In  temperate  countries  it  is  at  the 
time  of  their  pullulation — that  is,  during  the  hot  season 
— that  the  epidemic  curve  reaches  its  maximum. 
Further,  it  is  easy  to  realise  how  great  must  be  the 
influence  of  flies  when  one  considers  their  innumer- 
able flights,  from  faecal  matter,  where  they  gather 
the  bacilli  with  trunk  and  legs,  to  food-stuffs  of 
every  kind — meat,  vegetables,  bread,  milk,  pastry, 
cheese,  sweets,  etc.,  which  they  may  also  infect  with 
their  excrement.    If  we  feed  flies  (M.  domestica)  under 


CAUSES  OF  BACILLARY  DYSENTERY       355 

a  sterilised  bell-glass  on  a  culture  of  dysentery  bacilli 
the  bacilli  may  be  found  in  their  excreta  for  four 
days  afterwards.  Many  of  the  flies  succumb  (H. 
Vincent). 

Propagating  agents  of  great  mobility,  flies  bring  the 
pathogenic  bacilli  from  the  open  air  and  introduce  them 
into  dwelling-houses,  into  kitchens  and  dining-rooms, 
and  even  deposit  them  on  the  skin  of  the  face,  especially 
in  the  case  of  young  children.  They  have  "astly  been 
blamed  for  the  epidemics  observed  in  the  Ir  Jes,  and 
also  during  the  Spanish- American  War,  the  I  oer  War, 
the  Manchurian  Campaign  (Kolosky),  and  the  present 
war,  in  which  their  extraordinary  frequency,  during  the 
hot  season,  has  been  observed. 

They  may  also  infect  milk.  The  contamination  of 
milk  may  further  be  effected  by  farm  servants  afflicted 
with  dysentery  (Finny),  by  carriers  of  the  germ,  by 
its  mixture  with  impure  water,  or  by  the  employ- 
ment of  receptacles  which  are  unclean  and  specifically 
contaminated. 

It  goes  without  saying  that  it  is  only  the  drinking 
of  unboiled  milk  which  is  dangerous,  as  boiling  in- 
stantly destroys  the  bacillus.  Even  dried  milk,  cream 
cheese,  butter,  and  cheese  may  serve  as  receptacle  s  for 
bacilli  deposited  by  flies  or  by  human  hands,  and  will 
preserve  them  alive  for  some  days. 

It  was  formerly  believed  that  drinking-water  was  most 
commonly  concerned  in  the  propagation  of  epidemic 
dysentery.  This,  however,  does  not  appear  to  be  the 
case — at  all  events,  where  the  dysentery  bacillus  is 
concerned.  It  is  undeniably  a  fact  that  the  bacillus  may 
be  introduced  into  the  organism  by  means  of  drinking- 
water,  but  it  is  not  so  frequently  introduced  in  this 
way  as  is  the  bacillus  of  typhoid.  Shiga  has  recorded 
a  village  epidemic  due  to  water,  in  which  413  cases  were 
observed.  On  the  other  hand,  however,  a  large  number 
of  bacteriological  analyses  of  water,  made  at  the  very 
outset  of  various  epidemics  of  dysentery  in  the  Val-de- 
Grace  laboratory,  as  well  as  in  local  laboratories,  have 


356    DYSENTERY,  CHOLERA,  AND  TYPHUS 

only  as  an  exception  revealed  the  pollution  of  drinking- 
water. 

During  the  epidemics  observed  in  the  camp  of  Hussein- 
Dey,  in  1894  and  the  following  years,  the  water, 
furnished  by  an  artesian  well,  was  extremely  pure. 
On  the  occasion  of  the  malignant  epidemics  which 
occurred  in  the  garrison  of  Versailles  the  water,  which 
was  bacteriologically  examined  on  the  appearance  of 
the  first  cases,  was  irreproachable  in  quality.  The 
short  period  of  incubation  obtaining  in  dysentery  con- 
firms the  complete  validity  of  these  examinations. 

Similarly  Faichnie  has  reported  the  occurrence  of 
epidemics  in  the  British  Army,  although  the  men  were 
drinking  only  boiled  water  and  tea. 

It  may  be  concluded,  then,  that  drinking-water  may 
cause  an  outbreak  of  dysentery,  but  that  it  is  by  no 
means  the  most  important  propagating  agent  of  this 
disease. 

An  explanation  of  this  fact  is  that  water  is  not  a 
favourable  medium  for  the  preservation  of  the  Shiga- 
Flexner  bacillus,  while  it  is  even  less  favourable  to  its 
vegetation.  In  water  contaminated  by  numerous 
germs,  as  are  those  waters  to  which  the  dysenteric 
bacillus  makes  its  way,  together  with  all  the  rest  of  the 
bacilli  found  in  faecal  matter,  and  the  germs  of  putre- 
faction, the  bacillus  can  hardly  live  longer  than  two  or 
three  days.  It  quickly  becomes  rare,  and  then  dis- 
appears. The  saprophytic  microbes,  aerobic  or  anaerobic, 
exert  a  vigorous  competitive  action,  and  are  inimical 
to  its  survival,  especially  when  the  temperature  of  the 
water  is  fairly  high,  and  therefore  favourable  to  their 
multiplication. 

Flexner's  bacillus  is  a  little  more  resistant  in  water 
than  is  Shiga's  bacillus.  Both  are  very  sensitive  to 
light. 

Water  becomes  polluted  in  a  great  variety  of  ways. 
These  are  the  same  as  those  described  in  connection 
with  the  etiology  of  typhoid  fever,  the  paratyphoid 
fevers,   and   cholera  :    the  direct   discharge   of  faecal 


CAUSES  OF  BACILLARY  DYSENTERY        357 

matter  in  sewage  ;  the  action  of  rain,  which  washes 
the  soil  and  bears  impurities  along  with  it  ;  infiltration 
into  the  subsoil  ;  contamination  due  to  neighbouring 
cesspools  ;  the  use  of  faecal  matter  as  manure ;  the 
washing  of  the  linen  of  dysentery  patients  or  carriers, 
etc. 

In  cesspools  the  antagonistic  influence  of  sapro- 
phytic bacteria  considerably  diminishes  the  vitality  of 
the  dysentery  germ. 

Climatic  conditions  may  mitigate  this  automatic 
process  of  purification  in  the  water,  the  soil  and  the  sub- 
soil. Cold,  while  it  prevents  the  development  of  sapro- 
phytes, actually  helps  to  preserve  the  bacillus  of 
dysentery. 

This  is  an  interesting  fact,  and  worthy  of  record,  for 
it  partly  explains  the  persistence  of  dysentery  in 
northern  countries. 

In  lake  waters,  where  the  light  is  able  to  act  on  the 
germs  (the  luminous  rays  penetrating  to  a  maximum 
depth  of  five  metres),  the  superficial  strata  may  be 
purified,  but  the  deeper  levels  may  remain  contagious. 
The  same  conditions  obtain  in  the  waters  of  the  Durance 
and  the  Rhone. 

The  Spread  of  Epidemics 

Bacillary  dysentery  may  exist  endemically,  giving 
rise  to  isolated  cases,  but  it  more  often  occurs  in  epi- 
demics. Then,  especially  in  new  countries,  it  gives 
rise  to  numerous  cases,  occurring  rapidly  and  over  a 
wide  area,  attacking  a  large  number  of  victims  simul- 
taneously. Amongst  large  collections  of  people,  for 
example  in  barracks  and  schools,  where  human  contact 
is  frequent,  the  spread  of  epidemios  is  often  alarmirrg. 
Every  day  fresh  cases  appear — of  apparently  simple 
diarrhoea,  or  of  typical  dysentery.  The  epidemic  lasts 
a  few  days  or  weeks,  and  ceases,  either  because  the 
receptive  soil  has  become  exhausted,  or  because  effective 
prophylactic  measures  have  been  taken. 


358    DYSENTERY,  CHOLERA,  AND  TYPHUS 

In  country  districts,  where  the  rules  of  hygiene  are 
ignored,  where  dejecta  are  scattered  everywhere,  and 
where  children  maintain  the  epidemic  state  by  con- 
tracting attenuated  or  unrecognised  forms  of  the  dis- 
ease, dysentery  is  isometimes  more  tenacious,  and  may 
continue  for  several  months.  In  such  epidemics  the 
mortality  is  high. 

This  is  the  case  in  Japan,  where  dysentery  has  been 
prevalent 'for  centuries,  often  with  disastrous  effects. 
Between  1892  and  1896  it  caused  50,000  deaths 
(Shiga).  Between  1890  and  1900  there  were  875,534 
cases,  with  26-39  per  cent,  of  deaths. 

When  dysentery  breaks  out  in  a  small  village  it  is 
not  long  before  it  attacks  all  the  receptive  subjects 
(5  to  10  per  cent,  of  the  inhabitants  in  Japan).  In  the 
following  year  there  are  few  cases  or  none.  If  the  first 
appearance  of  the  epidemic  has  been  slight  or  moderate, 
a  more  violent  return  is  often  observed  in  the  following 
year.  In  the  third  year  no  cases  occur,  the  inhabitants 
having  become  immunised. 

In  towns  dysentery  attacks  more  especially  the 
populous  quarters  and  poor  families,  in  which  parents 
and  children  live  in  close  mutual  contact ;  here  there 
are  the  greatest  facilities  for  contaminating  one  another. 


CHAPTER  VI 

EPIDEMIOLOGY  OF  AMCEBIC  DYSENTERY 

The  existence  of  pathogenic  protozoa  in  the  intestines 
of  a  dysentery  patient  was  proved  by  Losch,  who 
succeeded  in  reproducing  the  disease  in  the  dog,  by 
causing  the  latter  to  absorb  dysenteric  dejecta. 

The  parasites  {Amoeba  coli,  Losch)  reproduce  them- 
selves by  division  and  by  the  formation  of  cysts,  which 
give  rise  to  several  daughter  amoebulse.^ 

Various  apparent  species  of  the  dysenteric  amoeba 
have  been  described  :  Entamoeba  histolytica,^  E.  tetra- 
gena,  E.  tropicalis,  E.  nipponica,  etc.  The  first  is  the 
most  frequent.  They  are  very  often  accompanied  by 
other  parasites  :  Trichomonas  intestinalis,  Lamblia,  etc. 
(Simonin).^ 

As  has  been  said,  amoebic  dysentery  is  more  especi- 
ally the  appanage  of  hot  and  tropical  countries.  Very 
common  in  India,  Cochin-China,  Tonkin,  Sumatra, 
Java,  Madagascar,  the  Sudan,  Central  Africa,  Egypt, 
Senegal,  etc.,  it  is  equally  prevalent  in  South  America, 
Brazil,  Cuba,  and  the  Philippines.  Tonkin,  and  above 
all  Saigon,  is,  for  the  French  troops,  a  dangerous  centrie 
of  amoebic  dysentery.     It  is  not  rare  in  Morocco. 

The  admirable  work  of  Osier,  and  of  Councilmann  and 
Lafleur,  and  the  important  investigations  of  Gasser  in 

^  A.  coli  dysenterice  is  a  more  explicit  denomination,  as  is  Entamoeba 
dysenterice.  The  latter  was  proposed  by  Councilmann  and  Lafleur. 
[A.  coli  dysenterice,  according  to  the  rules  of  nomenclature,  is  not  a  per- 
missible name,  however  suitable  it  may  be  as  a  descriptive  term. — Ed.] 

^  Entamoeba  histolytica  is  the  name  employed  in  England  at  present 
for  the  pathogenic  amoeba. — Ed. 

^  A  new  non-pathogenic  amceba  has  recently  been  described  by 
Wenyon  and  O'Connor  and  by  Dobell  and  Miss  Jepps.  It  has  been 
called  Entamoeba  nana — Ed. 

359 


360  DYSENTERY,  CHOLERA,  AND  TYPHUS 

Algeria,  of  Marchoux  in  Senegal,  and  of  Harris,  etc., 
have  helped  to  throw  light  upon  the  nature  and  the 
modes  of  transmission  of  this  form  of  dysentery. 

For  a  long  time  it  was  supposed  that  amoebic  dysen- 
tery could  not  exist  in  cold  or  temperate  countries,  save 
as  a  very  exceptional  malady,  or  one  affecting  subjects 
infected  in  the  colonies  or  other  hot  countries.  The 
discovery  of  the  Entamceba  in  a  certain  number  of 
cases  occurring  in  Russia,  at  Kiev  (Massioutine,  Kour- 
lov),  in  Prague  (H.  Lava),  in  France  (Landouzy  and 
Debre,  Caussade  and  Joltrain),  and  in  Spain  (Fidel 
Fernandez  Martinez),  as  well  as  the  more  recent  dis- 
coveries made  during  the  present  war,  in  the  case  of 
European  soldiers  infected  in  the  trenches  (Ravaut  and 
Krolunitsky,  Job,  Richet,  jun.,  Rist,  Rathery,  etc.),  has 
demonstrated  the  fact  that  this  disease  should  be  looked 
for,  and  is  perhaps  more  common  than  is  supposed,  in 
temperate  climates.  Amoebae  have  also  been  found  in 
cases  of  suppurative  hepatitis  in  Russia,  Austria,  Paris 
(Caussade  and  Joltrain),  etc. 

Having  made  their  way  into  the  alimentary  canal 
[as  cysts],  the  young  amoebulge  localise  themselves  in  the 
mucous  lining  of  the  large  intestine.  This  is  their  seat 
of  election.  They  may  also  be  found  in  the  vermi- 
form appendix,  where  they  may  give  rise  to  appendicitis 
(Harris)  ;  further,  they  frequently  occur  in  the  hepatic 
parenchyma,  where,  transported  by  the  veins,  they 
form  colonies,  giving  rise  to  actual  local  necrosis,  the 
hepatic  abscess.  Localisations  in  the  lungs,  spleen, 
brain,  and  articulations  are  more  unusual. 

In  the  intestine  the  amoebae  find  their  way  into  the 
Lieberkiihn  follicles,  and  then — after  the  destruction  of 
their  walls — into  the  glandular  interspaces,  the  sub- 
mucous tissue,  the  lymphatic  spaces,  the  capillary 
blood-vessels,  etc. 

The  infection  may  be  conveyed  by  inoculation  to  the 
dog  and  the  cat,  and  the  progress  of  the  parasite  may  then 
be  followed  through  the  elements  of  the  intestinal  walls. 

The  discovery  of  amoebae  in  abscesses  of  the  liver, 


EPIDEMIOLOGY  OF  AMCEBIC  DYSENTERY       361 

and,  above  all,  in  their  walls  (Rogers),  has  finally 
established  the  relations  which  Kelsch  had  stated  to 
exist  (basing  his  statement  on  clinical  observation  and 
pathological  anatomy)  between  dysentery  and  hepatitis. 

The  multiplication  of  amoebae  in  the  walls  of  the  large 
intestine  results  in  the  anatomical  destruction  of  the 
tissues  and  the  formation  of  extensive  ulcerations  of 
the  colon.  This  destruction  is  facilitated  by  additional 
microbic  infections. 

The  point  of  departure  of  the  amoebic  contagion  is  there- 
fore to  he  found,  as  in  hacillary  dysentery,  in  the  intestine 
of  the  patient,  and,  practically,  in  his  dejecta.  The  latter 
sometimes  contain  an  enormous  number  of  parasites 
(amoebae  or  cysts),  especially  in  recent  and  acute  cases. 
They  are,  however,  also  numerous  in  the  chronic  forms, 
and  come  from  the  intestinal  ulcerations  and  their 
secretions. 

It  should  be  added  that  when  dysenteric  abscesses  of 
the  liver  have  found  an  external  opening,  usually 
through  the  right  lung  and  a  bronchial  fistula,  the  para- 
sites exist  in  the  vomicae,  and  may,  though  the  case  is 
rather  exceptional,  be  transmissible  by  this  secretion. ^ 

Unlike  bacillary  dysentery,  which  almost  always 
follows  an  acute  development,  amoebic  dysentery 
habitually  becomes  chronic  when  the  treatment 
opposed  to  it  is  insufficient.  Bacillary  dysentery  im- 
munises the  infected  subject ;  amoebic  dysentery  does 
not.  It  follows  from  this  that  in  patients  suffering 
from  chronic  amoebic  dysentery  the  excretion  of  the 
parasites  is  a  very  long  process.  But  this  is  not  all. 
In  soldiers  recalled  from  Tonkin,  etc.,  and  returning  to 
France,  the  faeces  may,  after  (apparent)  recovery,  still 
contain  A.  coli  dysenterice  [E.  histolytica]  or  its  cysts. 
Sometimes  these  patients  have,  or  appear  to  have, 
entirely  recovered  ;  sometimes,  at  irregular  intervals, 
they  suffer  from  attacks  of  diarrhoea.  They  are  true 
carriers  of  amoebae  or  their  cysts.     There  are  even  some 

^  If  this  were  so  it  would  mean  that  cysts  were  formed  in  these 
situations.     There  is  no  proof  so  far  of  such  an  occurrence, — Ed. 


^Q2  DYSENTERY,  CHOLERA,  AND  TYPHUS 

who  suffer  from  a  return  of  dysentery  after  a  remission 
of  six  or  eight  months,  or  even  a  year  (H.  Vincent). i 
These  carriers  are  propagating  agents  of  the  dysentery 
amoeba,  through  the  medium  of  their  excreta.  Cysts 
may  be  found  in  healthy  subjects  dwelhng  in  infected 
countries  (Mathis,  Ravaut  and  Krolunitsky). 

It  is  easy  to  understand  how  amoebic  contagion  is 
effected  among  soldiers  fighting  at  the  front  or  Hving  in 
cantonments.  This  is  the  explanation  of  the  fact  that 
cases  occur  among  soldiers  who  have  never  been  in  the 
colonies. 

In  times  of  peace,  moreover,  numerous  examples  of 
amoebic  contagion  have  been  observed  on  board  vessels 
returning  to  France  with  convalescents,  healthy  subjects, 
and  dysentery  patients  simultaneously.  In  a  barracks 
occupied  by  colonial  troops,  at  Toulon,  some  soldiers 
living  in  contact  with  comrades  who  had  returned  from 
the  colonies  contracted  amoebic  dysentery  (H.  Vincent). 

As  the  pathogenic  agent  of  amoebic  dysentery  resides 
exclusively  in  the  faeces,  it  is  accordingly  susceptible  of 
being  directly  transmitted  by  the  latter. 

Immediate  contagion,  therefore,  is  the  propagating 
agent  of  the  amoeba.  Instances  have  been  published 
of  contagion  in  hospital  orderlies  or  persons  living  in 
contact  with  patients  suffering  from  amoebic  dysentery 
(Dopter,  H.  Vincent,  Lemoine).  Again,  the  patient 
may  contaminate  those  surrounding  him  by  touching 
articles  of  food  with  unclean  hands.  On  the  other 
hand,  the  absence  of  precaution  on  the  part  of  those 
who  are  tending  the  dysentery  patient  may  transfer 
the  germ  in  the  same  way. 

Experimentally,  if  young  kittens,  infected  by  the  rec- 
tum, are  placed  in  a  cage  together  with  other  healthy 
ones,  the  latter  may  acquire  dysentery  by  contagion. 
Female  cats,  suckling  their  infected  young  and  licking 
them,  will  contract  dysentery.  A  post-mortem  examin- 
ation reveals  innumerable  amoebae  in  the  large  intestine. 

^  Low  has  recently  described  a  case  of  liver  abscess  occurring  twenty 
years  after  the  original  attack  of  dysentery. — Ed. 


EPIDEMIOLOGY  OF  AMCEBIC  DYSENTERY      363 

They  are  sometimes  found  in  the  small  intestine  as 
well. 

The  indirect  transmission  of  A.  coli  dy sentence 
\E.  histolytica^  is  rendered  possible  by  the  fact  that  the 
parasite,  although  rather  lacking  in  vitality,  is  yet  able 
to  survive  by  living  in  the  encysted  state,  thereby  re- 
sisting the  natural  causes  of  destruction. 

In  the  ordinary  state,  not  encysted,  it  is  killed  in 
thirty-five  minutes  at  45°  C.  (Marchoux)  by  gastric  juice, 
acids,  antiseptics,  etc.  Urine,  even  when  neutralised, 
destroys  amoebae  (Harris).  Boric  acid  does  not  appear 
to  have  any  appreciable  effect,  but  osmic  acid 
and  sublimate  instantaneously  arrest  the  amoeboid 
movements.  Experiments  made  with  recent  stools  of 
dysentery  patients  have  given  the  following  further 
results  : — Solutions  of  permanganate  of  potash  act 
feebly  on  Entamoebse ;  solutions  of  tartaric  acid, 
citric  acid,  oxalic  acid,  and  more  particularly  of  tannin, 
and  oxygenated  water,  kill  them  rapidly  (Harris). 
Neutral  hydrochlorate  of  quinine  [Quinine  bihydro- 
chloride],  even  in  very  minute  quantities,  in  a  solution 
of  0-50  gr.  to  1  c.c.  of  water,  placed  at  the  edge  of  the 
cover-glass,  has  an  overwhelming  effect.  The  amoebae 
become  instantly  retracted,  forming  unrecognisable 
masses.  They  are  quickly  killed  by  Labarraque's 
solution  (5  or  10  per  1000),  less  quickly  (in  one  to 
five  minutes)  by  a  solution  of  methylene  blue  or  by 
neutral  red  (H.  Vincent). 

The  amoeba  of  dysentery,  however,  resists  desiccation, 
thanks  to  its  property  of  forming  cysts.  It  is  not 
always  destroyed  by  freezing  (Kiinen  and  Swellengrebel). 
If  kittens  are  made  to  swallow  fresh  dysenteric  dejecta 
they  do  not  contract  the  disease,  but  if  the  dejecta  are 
allowed  to  dry  the  parasites  have  time  to  become 
encysted,  and  the  animals  acquire  the  disease.  The 
cysts  resist  the  gastric  juice,  but  in  the  small  intestine 
their  envelope  is  dissolved  by  the  alkaline  secretion  of 
the  latter,  and  on  reaching  the  large  intestine  they 
proceed  to  multiply. 


364    DYSENTERY,  CHOLERA,  AND  TYPHUS 

This  explains  why  the  dysentery  amoeba  is  able  with 
impunity  to  traverse  the  stomach,  despite  the  presence 
of  the  gastric  secretion,  to  which  it  is  susceptible,  as  to 
all  acids. 

Its  transmission  by  means  of  food- stuffs,  fruits,  vege- 
tables, etc.,  contaminated  by  the  spreading  of  manure, 
is  therefore  possible.  Flies  are  probably  capable  of 
transporting  it  by  means  of  their  legs  or  their  dejecta, 
and  there  is  room  for  further  investigation  in  this 
direction.  1 

It  has  sometimes  been  suggested  that  contagion  may 
be  effected  by  means  of  the  seats  of  closets,  or  rectal 
catheters  or  thermometers  which  have  not  been  dis- 
infected. 

Another  fact  of  great  importance  is  that  the  patho- 
genic amoeba,  above  all  in  the  encysted  state,  is  capable 
of  survival  for  at  least  nine  to  thirteen  days  in  water, 
such  as  well-water,  ditch-water,  or  the  water  of  ponds, 
where  it  is  able  to  enjoy  a  certain  amount  of  obscurity. 
It  has  not  been  observed  that  it  multiplies  there,  but  the 
fact  of  its  survival  explains  the  frequent  transmission 
of  dysentery  by  means  of  polluted  water.  It  is  possible 
that  the  amoeba  is  able  to  multiply  in  muddy  places, 
for  when  in  the  human  intestine  it  is  able  to  feed  on 
bacteria  as  well  as  on  the  corpuscles  of  the  blood.^  The 
dysentery  amoeba  is,  therefore,  enabled  to  resist  a 
certain  number  of  natural  causes  of  destruction  owing 
to  its  property  of  becoming  encysted. 

One  of  the  best  established  and  most  frequent  modes 
of  propagation  of  the  amoeba  results  from  the  absorp- 
tion of  polluted  water.  It  has  been  noted  that  this 
parasite  subsists  in  water.  Long  ago  Leon  Colin  in 
Algeria,  H.  Blanc  in  Abyssinia,  Lalluyaux  d'Ormay  in 
Cochin-China  and  Barailler  in  Guadeloupe  called  atten- 

^  Vide  Wenyon  and  O'Connor's  recent  experiments,  and  the  work  of 
J.  G.  &  D.  Thomson  in  Egypt.— Ed. 

2  There  is  no  evidence  of  this.  The  living  amcfba?  quickly  die  when 
they  leave  the  body.  So  far  they  have  never  been  cultivated.  It  is 
by  the  cysts  that  propagation  takes  place. — Ed. 


EPIDEMIOLOGY  OF  AMCEBIC  DYSENTERY       365 

tion  to  the  important  part  played  by  drinking-water  in 
the  etiology  of  dysentery.  In  Guadeloupe  it  was  re- 
marked that  while  the  water  of  the  River  Dugommier 
was  productive  of  dysentery,  the  water  of  the  tanks  and 
cisterns  was  not.  A.  Calmette  has  noted  that  the 
epidemic  of  dysentery  which  prevailed  in  the  arrondisse- 
ment  of  Loctrang,  in  Cochin-China,  disappeared  when 
water  filtered  by  Chamberland  filters  was  provided. 
In  the  Dutch  Indies  the  employment  of  purified  water 
has  yielded  equally  favourable  results. 

Serious  epidemics  of  dysentery  used  formerly  to  be 
observed  on  board  warships,  which  were  attributed  to 
the  drinking  of  water  drawn  from  the  rivers  of  the  Far 
East,  particularly  in  Saigon  and  Hong-Kong. 

Amoebic  dysentery  is  thus  almost  always  associated 
with  a  defective  hygiene  or  a  bad  food-supply.  It  is 
observed  among  the  poor  populations  of  hot  countries, 
and  in  soldiers  suffering  from  sea-sickness  and  im- 
properly fed,  or  who  do  not  observe  any  precautions. 

It  is  a  malady  of  all  seasons,  but  is  nevertheless  more 
common  in  summer.  It  is,  according  to  Harris,  less 
frequent  in  children  than  in  adults. 

All  the  epidemiological  data  which  have  just  been 
given  apply  equally  to  the  suppurative  hepatitis  of  hot 
countries,  which  is  nothing  but  a  hepatic  dysentery. 
The  history  of  hepatic  abscess  is,  indeed,  as  closely 
bound  up  with  that  of  dysentery  as  is  the  history  of 
orchitis  with  that  of  mumps.  The  geographical  distri- 
bution of  the  two  diseases  is  the  same,^  and  the  fre- 
quency, or  even  the  mere  existence  of  hepatic  abscess 
in  a  district  enables  one  to  affirm  the  presence  of  amoebic 
dysentery.  This  is  why  suppurative  hepatitis,  so  often 
observed  in  hot  or  tropical  countries,  is  very  exceptional 
in  cold  or  temperate  countries,  where  bacillary  dysentery 
is,  on  the  contrary,  predominant,  if  not  exclusive. 

Even  before  the  discovery  of  Entamoebse  in  the  walls 
of  the  abscess  (Dock,  Osier,  etc.),  the  specific  nature  of 

^  Though  this  is  so,  some  parts  of  the  tropics  show  many  more  cases 
of  liver  abscess  than  others.     India  for  example. — Ed. 


366  DYSENTERY,  CHOLERA,  AND  TYPHUS 

the  latter  had  been  affirmed  by  Kelsch,  and  also  by- 
La  veran,  Netter,  and  Peyrot.  Marchoux  succeeded  in 
causing  amoebic  abscesses  by  injecting  pus  from  dysen- 
teric abscesses  into  the  portal  vein  of  a  cat. 

Amoebic  hepatitis  is  most  frequently  preceded  by 
a  characteristic  or  ill-defined  dysentery.  In  certain 
cases,  however,  the  abscess  of  the  liver  may  precede  the 
dysentery,  or  may  even  occur  in  the  absence  of  any 
appreciable  condition  of  dysentery.  The  hepatitis 
then  represents  the  primary  localisation  of  the  amoeba, 
but  its  initial  penetration  by  way  of  the  intestine,  and 
thence  through  the  portal  radicles,  does  not  appear  to 
be  in  doubt. ^ 

We  have  yet  to  speak  of  mixed  cases  of  dysentery 
— ^that  is,  cases  where  the  subject  is  infected  simul- 
taneously by  the  bacillus  of  dysentery  and  the  Entamoeba 
dy sentence  \E.  histolytica].  The  first  discovery  of  these 
dysenteries,  which  we  shall  call  amoebo-bacillary 
dysenteries,  was  made  by  Strong,  in  the  Philippines  and 
the  United  States.  Having  examined  246  cases  of 
dysentery  in  the  Philippines,  he  found  that  193  were 
amoebic,  50  were  bacillary,  and  3  were  mixed. 

While  the  present  war  against  Germany  has  enabled 
us  to  verify  cases  of  autochthonous  amoebic  dysentery 
in  France,  it  has  also  afforded  opportunities  of  observing 
cases  in  which  the  patient  was  infected  simultaneously 
with  bacillary  and  amoebic  dysentery.  In  August,  1915, 
P.  Ravaut  and  Krolunitsky  described  a  mixed  epidemic, 
sometimes  attacking  men  belonging  to  the  colonial  or 
Morocco  regiments,  and  sometimes  soldiers  of  all  ages 
who  had  never  left  France,  but  who  had  been  living  in 
contact  with  the  former,  or  occupying  the  same  trenches. 

Roussel,  Brule,  Baral,  and  A.  P.  Marie  have  made 
bacteriological  observations  similar  to  those  of  the 
above-mentioned  writers. 

It  is  as  well  to  be  aware  of  the  existence  of  these 

^  Autopsies  certainly  bear  this  out,  signs  of  ulceration,  old  or  recent, 
being  present  in  the  large  intestine. — Ed. 


EPIDEMIOLOGY  OF  AMCEBIC  DYSENTERY       367 

amoebo-bacillary  cases,  although  they  are  not  very 
common  as  compared  with  the  individual  cases  of 
bacillary  or  amoebic  dysentery. 

There  are  also,  for  that  matter,  unconnected  with 
the  circumstances  of  warfare,  epidemics  in  which 
sometimes  the  dysentery  bacillus  and  sometimes  the 
Amoeba  coli  dy sentence  \E.  histolytica]  are  encountered 
in  members  of  the  same  group  of  people.  Strong  and 
Musgrave  found  that  out  of  1328  cases  of  dysentery 
occurring  among  the  American  troops  under  treatment 
in  No.  1  Reserve  Hospital,  in  Manila,  in  ten  months, 
561  were  of  the  amoebic  type,  while  766  were  bacillary. 

Nevertheless,  the  fact  remains  that  cases  of  mixed 
dysentery  may  be  observed,  and  this  is  a  point  of  great 
interest  from  the  epidemiological  and  prophylactic  as 
well  as  from  the  therapeutical  point  of  view. 

There  are  other  affections  which  enter  into  the 
dysenteric  syndrome,  but  which,  by  reason  of  their 
rarity,  have  not  the  great  importance  of  the  diseases 
already  discussed. 

In  their  writings  on  dysentery  Councilmann  and 
Lafleur  were  the  first  to  express  the  opinion  that  dysen- 
tery is  not  a  single  disease,  but  "  that  there  are  dysen- 
teries just  as  there  are  broncho-pneumonias."  Although 
very  greatly  predominant,  bacillary  dysentery  and 
amoebic  dysentery  are  not,  properly  speaking,  the 
only  forms  of  dysentery.  Balantidium  coli  (Strong 
and  Musgrave),  Chilodon  dentatus  (Guiart),  Schistosoma 
mansoni,  a  special  spirillum  (Le  Dantec),  and  kala-azar 
parasites  (Leishman-Donovan  bodies),  etc.,  may  give 
rise  to  an  acute  or  chronic  colitis,  which  is  closely 
analogous  to  the  classical  form  of  dysentery. 

The  truth  is  that  the  living  organism  cannot  oppose 
infecting  germs  by  an  unlimited  number  of  reactions. 

Balantidium  coli  exists  in  great  profusion  in  the 
ulcerations  and  the  walls  of  the  large  intestine  of  the 
sufferer,  as  well  as  in  his  evacuations.  Its  vitality  out- 
side the  living   organism   is  increased  by  its    power 


368   DYSENTERY,  CHOLERA,  AND  TYPHUS 

of  becoming  encysted.  The  cysts  (80/z  to  lOOju-  in 
diameter)  are  formed  more  particularly  under  the 
influence  of  desiccation.  This  ciliate,  when  not  in  the 
encysted  state,  is  very  fragile,  and  sensitive  to  acids 
(even  when  diluted  to  a  strength  of  1  in  1000),  to 
quinine  (1  in  1500)  (Klimenko),  etc.  It  may  live  for 
three  days  in  water. 

Conmion  enough  in  the  pig,  Balantidium  coli  is 
probably  transmitted  by  the  latter,  or  else  by  the  de- 
jecta of  patients  suffering  from  this  form  of  dysentery  ; 
but  only  when  the  parasite  has  assumed  the  encysted 
form,  which  protects  it  against  the  action  of  the  gastric 
juice.  The  Balantidian  form  of  dysentery  is  observed 
more  particularly  among  pork  butchers. 

Attempts  at  experimental  inoculation  of  animals 
have,  however,  failed  (Manson),  and  such  experiments 
have  also  failed  even  with  human  subjects,  despite  the 
existence  of  cystic  bodies  (Grassi  and  Calandruccio). 

The  existence  of  Chilodon  dentatus  has  been  noted  by 
Guiart  in  the  dejecta  of  a  patient  exhibiting  a  dysenteric 
syndrome.^  Billet  considers  that  Trichomonas  intes- 
tinalis  may  also  produce  an  analogous  disease.  He  has 
observed  four  cases  of  this  kind.  Bilharziasis,  accord- 
ing to  Manson,  is  transmitted  by  the  embryo  of  the 
Schistosoma,  which,  having  reached  the  water,  finds 
its  way  into  the  body  of  a  fresh-water  animal,  and 
through  the  mediimi  of  the  latter  enters  the  human 
host.  Drinking-water  is  thus  the  infecting  agent  in 
Bilharziasis.  2 

^  As  already  pointed  out,  vide  page309  Chilodon  dentatus  is  a  free 
living  protozoon  and  not  parasitic.  It  can  be  found  in  ordinary  water 
taps.  Its  occurrence  in  Guiart's  case  must  then  have  been  purely 
accidental,  from  some  water  contamination. — Ed. 

2  Leiper  has  recently  demonstrated  in  Egypt  that  the  bilharzial 
miracidium  passes  into  a  mollusc.  After  having  developed  in  the 
tissues  of  the  snail,  cercaria  appear  and  escape  into  the  water. 
From  there  they  pass  directly  through  the  skin  of  the  human  host,  and 
so  bring  about  the  infection.  Wading  or  bathing  in  infected  water  is 
very  dangerous,  and  will  speedily  result  in  the  acquisition  of  the  disease. 

Schistosoma  japonicum  infections  are  brought  about  in  the  same 
way. — Ed, 


CHAPTER  VII 

PROPHYLAXIS    OP    BACILLARY   AND 
AMCEBIC    DYSENTERIES 

Bacillary  dysentery  and  amoebic  dysentery  present  a 
large  number  of  common  etiological  factors. 

The  prophylaxis  of  the  two  diseases  accordingly 
comprises  rules  which  are  applicable  to  either.  All 
disorders  of  intestinal  determination  may,  from  this 
point  of  view,  be  classed  together,  and  the  prophylactic 
measures  recommended  in  the  case  of  cholera  will 
equally  apply  here. 

Among  the  measures  which  bear  upon  the  favouring 
causes,  the  medical  officers  of  the  navy  and  colonial 
physicians  especially  recommend  the  avoidance  of 
chills  in  the  abdomen  in  those  countries  where  dysentery 
is  prevalent.  One  should  certainly  not  disdain  the 
influence  of  ""  secondary "  causes,  and  supervision 
should  be  exercised  over  the  diet,  which  in  times  of 
epidemic  ought  to  be  wholesome  and  simple  and  free 
from  indigestible  material. 

The  abuse  of  biscuits,  and  preserved  meats,  and  the 
absence  of  fresh  food  have  been  incriminated,  in  time  of 
war  (the  Crimean  and  Balkan  wars),  as  factors  which 
irritate  the  mucous  membranes  of  the  digestive  tract 
and  cause  indigestion.  The  diarrhoea  known  as 
"  trench  diarrhoea  "  may,  as  a  matter  of  fact,  be  due  to 
various  germs  :  enterococcus,  Proteus  vulgaris,  etc.,  as 
well  as  the  dysentery  bacillus. 

The  general  cleanliness  of  dwelling-houses,  barracks, 
privies,  latrines,  etc.,  and  their  surroundings,  is 
evidently  a  condition  favourable  to  proper  hygiene. 
In  working-class  dwellings  and  poor  quarters  it  should 

369 


370    DYSENTERY,  CHOLERA,  AND  TYPHUS 

be  seen  that  this  condition  is  fulfilled,  as  well  as  that  of 
individual  cleanliness,  and  it  is  important  to  combat 
alcoholism  and  take  measures  to  prevent  physiological 
want  and  over-exertion,  which  are  predisposing  factors 
of  infectious  diseases. 

Microbic  or  parasitic  prophylaxis  ought  to  include  the 
compulsory  notification  of  cases  of  bacillary  or  amoebic 
dysentery,  owing  to  the  gravity  of  these  diseases,  the 
frequency  of  epidemics,  and  the  excessively  contagio,us 
nature  of  the  germ. 

This  is  why  the  isolation  of  patients  attacked  by 
bacillary  dysentery  must  at  once  be  effected.  The 
evolution  of  this  malady  is  generally  brief  (although 
chronic  forms  exist),  which  may  facilitate  this  measure. 

Further,  it  is  necessary  to  take  precautions  in  respect 
to  convalescents  and  subjects  who  are  or  may  become 
carriers  of  the  germ.  Consequently  recourse  to  the 
laboratory  is  an  indispensable  part  of  the  rational 
prophylaxis  of  dysentery.  In  the  army  these  labora- 
tories, which  in  time  of  peace  already  existed  in  each 
regional  division,  have  rendered  great  service  in  the 
early  diagnosis  of  infectious  diseases  and  in  hunting 
out  carriers  of  bacilli.  Similarly,  in  time  of  war  the 
laboratory  of  the  army  corps  or  army  should  be  con- 
sulted as  to  the  exact  diagnosis  of  dysenteries. 

Whatever  the  pathogenic  agent  may  be,  the  dejecta 
are  certainly  the  medium  of  its  propagation.  It  is 
therefore  necessary  to  disinfect  them  as  soon  as  emitted, 
by  means  of  creosol,  lysol,  or  a  5  per  cent,  solution  of 
copper  sulphate,  a  little  hydrochloric  acid  being  added 
to  this  last  if  needful.  Sulphate  of  iron  is  not  an 
efficient  antiseptic. 

Latrines,  cesspits,  and  their  approaches,  in  camps  in 
time  of  war,  should  be  generously  sprinkled  with 
chloride  of  lime,  once  a  day  in  winter,  twice  a  day  in 
summer.  The  installation  of  the  water-carriage  system 
of  drainage  in  barracks  is  a  measure  of  the  greatest 
utility. 

Laboratory  examinations  should  be  made,  not  only  in 


BACILLARY  AND  AMCEBIC  DYSENTERIES    371 

those .  cases  of  dysentery  which  are  characteristic  in  their 
clinical  aspect,  but  also  in  ill-defined  or  attenuated  forms 
of  the  disease,  in  cases  of  benign  diarrhoea,  and  in  the 
sporadic  cases  which  are  the  forerunners  of  an  epi- 
demic and  which  are  very  often  due  to  the  specific 
agent  of  the  disease.  During  the  course  of  the  epi- 
demic these  merely  diarrhoeal  forms  are  no  less  con- 
tagious. It  is  therefore  necessary  to  take  the  same 
precautions  as  to  isolation  and  disinfection  where 
these  are  concerned,  and  to  give  the  patients  due 
attention. 

Everything  that  may  have  been  contaminated  by 
the  dejecta  is  dangerous.  It  is  therefore  as  well  to 
warn  the  patients  themselves  of  their  contagious 
condition. 

The  bacteriological  analysis  of  drinking-water  should 
be  made  immediately  upon  the  appearance  of  cases  of 
dysentery,  whether  in  town  or  in  country,  or  in  houses 
where  wells  are  the  source  of  supply.  The  same 
measure  is  obviously  to  be  applied  to  soldiers,  who  must 
be  forbidden  to  visit  taverns  and  public-houses  where 
non-purified  water  is  served. 

It  must  be  remembered  that  amoebic  dysentery  in 
particular  is  very  frequently  due  to  the  employment  of 
contaminated  water  or  food.  Water  should,  therefore, 
before  use,  be  sterilised  by  boiling  or  filtration,  and 
vegetables  and  fruits  should  be  cooked. 

All  the  prophylactic  measures  which  have  just  been 
mentioned  are  of  particular  importance  in  time  of  war, 
when  the  incessant  contamination  of  the  soil,  sub-soil, 
and  water  supplies,  the  frequent  presence  of  germ- 
carriers,  and  the  inactivity  obtaining  in  cantonments, 
and,  above  all,  in  the  trenches,  result  in  exposing  the 
soldier  to  constant  contagion.  The  prophylactic 
measures  taken  should  accordingly  be  particularly 
stringent,  for  the  dysentery  which  visits  armies  in  the 
field  is  often  of  alarming  gravity.  The  medical  officer 
should  pay  special  attention  to  the  cleanliness  of 
latrines,  etc.,  their  rigorous  and  repeated  disinfection. 


372  DYSENTERY,  CHOLERA,  AND  TYPHU8 

the  elimination  of  dung-hills,  the  scavenging  of  roads 
and  water-courses,  the  filling  in  of  depressions  in  the 
soil  and  the  systematic  destruction  of  flies,  those  dis- 
astrous carriers  of  disease  germs. 

As  regards  human  germ-carriers,  we  know  that  the 
carriers  of  dysentery  bacilli  do  not  retain  these  microbes 
very  long.  Such  individuals  should  be  isolated  and 
subjected  to  intestinal  disinfection.  Those  who  are 
chronic  carriers  of  amoebae  may  efficaciously  be  treated 
by  a  daily  enema  of  Labarraque's  solution  (8  or  10  per 
1000),  preceded  by  an  ordinary  enema  to  produce 
evacuation  (Vincent). ^ 

Military  patients  are  often  dilatory  in  presenting 
themselves  for  examination^  fearing  to  be  placed  on 
diet,  or  hoping  to  avoid  being  sent  to  hospital.  In 
this  way  the  pathogenic  bacillus  very  quickly  spreads 
through  the  barracks,  cantonments,  camps,  or  trenches. 
It  is  therefore  necessary,  directly  the  first  cases  make 
their  appearance,  to  request  the  men,  by  means  of 
notices  and  by  word  of  mouth,  to  consult  the  medical 
officer  immediately  any  suspicious  symptoms  appear. 

The  clothing  belonging  to  dysentery  patients,  and 
carriers  of  germs,  especially  their  underclothes  (vest, 
shirt,  and  pants),  with  trousers,  sheets,  etc.,  should  at 
once  be  sent  to  the  oven  for  disinfection. 

Healthy  subjects,  and  those  who  are  tending  the  sick, 
as  well  as  carriers  of  germs,  should  wash  their  hands 
frequently,  especially  when  they  have  to  handle  articles 
of  food. 

The  careful  washing  of  the  hands  before  meals  should 
be  recommended,  in  order  to  prevent  the  propagation 
or  ingestion  of  the  dysentery  bacillus  or  amoeba.  As 
regards  the  amoeba,  the  hands  must  be  washed  if  they 
are  soiled  with  earth,  mud,  filth  of  any  sort,  or  vegetable 

^  The  antiseptic  enema  should  be  administered  warm  (98  "4°  F. ),  drop 
by  drop,  very  slowly,  the  subject  lying  in  the  right-hand  dorso-lateral 
decubitus. 

[Such  injections  probably  never  reach  the  caecum  and  upper  parts 
of  the  colon.  If  the  dysenteric  ulcers  are  situated  there  they  can  have 
no  effect  upon  them. — Ed.] 


BACILLARY  AND  AMCEBIC  DYSENTERIES  373 

refuse  ;  lastly,  and  above  all,  if  there  has  been  any 
contact  with  a  dysenteric  patient. 

In  civil  or  military  hospitals  the  various  measures 
relating  to  the  sick  and  their  personal  effects  are  easily 
taken.  It  is  otherwise  in  the  case  of  poor  families  and 
in  country  districts,  the  ignorance  of  the  inhabitants 
in  respect  of  the  rules  of  prophylaxis  being  absolute. 
This  explains  the  prompt  diffusion  of  the  bacillus  of 
dysentery.  Sanitary  or  medical  officers  should  visit 
such  districts  and  give  practical  advice  to  all  the 
inhabitants. 

As  regards  permanent  camps,  we  cannot  too  strongly 
insist  that  they  should  be  situated  on  high  ground,  on  a 
sloping  surface,  and  that  all  roads,  as  well  as  the  ground 
on  which  the  tents  or  huts  are  erected,  should  be  made 
impermeable.  Flagged  or  tarred  surfaces  will  be  found 
extremely  serviceable. 

If  an  initial  case  of  dysentery  occurs  the  patient  must 
be  immediately  isolated.  His  effects  and  his  bedding 
must  be  disinfected  ;  the  tent  should  be  struck,  the 
canvas  disinfected,  and  all  straw  bedding  burned  on  the 
spot.  The  patient  must  never  be  tended  on  the  spot, 
but  must  be  sent  into  hospital. 

Dejecta  are  usually  received  by  the  soil  (cesspits),  or 
by  portable  tubs.  It  would  be  preferable,  in  perma- 
nent camps  in  time  of  peace,  to  install  water-carriage 
systems  of  drainage,  or  to  destroy  all  dejecta  by  means 
of  heat,  in  special  destructors  such  as  have  been  pro- 
posed for  the  purpose ;  but  these  measures  have  not 
yet  been  adopted. 

Consequently,  sites  must  be  avoided  which  have 
previously  been  occupied  by  soldiers  suffering  from 
dysentery.  It  has  been  recommended  (at  the  camp  of 
Chalons)  that  infected  emplacements  should  be  ploughed 
up  and  cultivated. 

The  latrines  and  their  approaches  should  be  lit  at 
night,  and  the  deposition  of  dejecta  elsewhere  than  in 
these  places  must  be  strictly  prohibited. 

Contamination  of  the  soil  by  the  accumulation  of 


374  DYSENTERY,  CHOLERA,  AND  TYPHUS 

excrement  is  to  be  avoided.  If  cesspits  are  employed 
they  should  be  as  far  as  possible  from  kitchens  and 
mess-roortis  or  tents,  as  well  as  from  stables  or  horse- 
lines  ;  and  they  should  not  be  situated  in  a  quarter  of 
the  camp  from  which  prevailing  winds  blow.  When 
the  cesspits  are  filled  and  their  contents  covered  up 
after  disinfection,  their  position  should  be  indicated  by 
a  sign-post. 

Depressions  in  the  soil  in  the  neighbourhood  of 
kitchens,  tents,  huts,  etc.,  should  be  filled  up  with 
rubble,  clinkers,  etc.  Measures  should  be  taken  to 
prevent  the  accumulation  of  stagnant  water,  kitchen 
refuse,  dung-hills,  manure-pits,  etc. — in  a  word,  any- 
thing that  may  attract  flies  and  harbour  pathogenic 
germs. 

Soldiers  suffering  from  dysentery  or  diarrhoea,  and 
recognised  carriers  of  dysentery  bacilli  or  amoebae,  must 
be  strictly  forbidden  to  enter  the  kitchens  and  must  on 
no  account  assist  in  the  preparation  of  food. 

Cooks,  butchers,  pork  butchers,  pastry-cooks,  dairy- 
men, etc.,  who  are  suffering  from  dysentery  or  are 
carriers  of  germs,  are  active  and  almost  always  un- 
recognised propagators  of  the  disease. 

In  times  of  epidemics,  or  in  hot  countries  where 
amoebic  dysentery  is  prevalent  as  an  endemic  disease, 
it  must  be  remembered  that  flies  often  carry  the  germ. 
Accordingly,  kitchens,  dining-rooms,  and  mess-rooms, 
etc.,  should  be  provided  with  screens  of  wire  gauze  fitted 
into  the  windows  and  over  the  doorways  ;  these  will . 
exclude  the  flies.  Food  must  be  protected  by  means  of 
dish-covers  or  covered  with  clean  napkins. 

The  destruction  of  flies  may  be  effected  by  means  of 
fly  papers  or  catchers  (adhesive  or  poisonous),  or  fly- 
traps, or  by  placing  on  the  tables,  at  night,  plates  con- 
taining ordinary  beer,  with  the  addition  of  ith  part  of 
formalin.     This  mixture  is  a  perfect  fly-killer. 

During  epidemics  the  use  of  raw  vegetables  (radishes, 
salads,  etc.),  and  fruits  is  to  be  forbidden,  as  these  may 
have  been  contaminated  by  faecal  matter,  either  by  the 


BACILLARY  AND  AMCEBIC  DYSENTERIES  375 

hands  of  germ-carriers  or  by  flies.  In  the  army  the 
medical  officer  should  supervise  the  bill  of  fare  of  each 
company. 

During  the  Manchurian  War  the  Japanese  derived 
some  advantage  from  the  daily  employment  of  creosote 
pills  as  a  preventive. 

Preventive  serotherapy  affords  protection  only  for  a 
limited  number  of  days  (ten  to  fifteen  at  most),  and 
consequently  is  not  a  practical  measure.  It  is  not  to 
be  recommended,  especially  as  regards  large  bodies  of 
men.     It  might  be  employed  in  families. 

Active  immunisation  by  means  of  cultures  derived 
from  dysentery  bacilli  has  not  up  to  the  present  become 
a  matter  of  current  practice.  Shiga  made  experiments 
in  the  vaccination  of  animals.  He  mixed  dead  cultures 
with  an  anti-dysenteric  serum,  and,  having  sensitised 
them,  injected  them  into  a  rabbit ;  the  latter  was  then 
able  to  receive  non-sensitised  vaccine,  and  then  the 
living  virus. 

Having  vaccinated  himself,  Shiga  reported  a  consider- 
able degree  of  painful  oedema  at  the  site  of  the  injection, 
with  fever,  severe  headache,  etc.,  lasting  for  several 
days. 

Between  1898  and  1900  he  vaccinated  10,000  Japanese 
by  means  of  dead  cultures,  first  sensitised  and  then  not 
sensitised.  The  dose  first  injected  was  half  a  platinum 
loopful  of  a  culture  twenty-four  hours  old,  sown  on 
agar.  Four  days  later  he  injected  twice  as  much,  not 
sensitised.  The  injection  was  made  into  the  cellular 
tissue  of  the  lumbar  region. 

The  only  result  of  this  experiment  was  the  diminu- 
tion of  the  death-rate,  which,  among  the  vaccinated,  fell 
to  0.     But  the  morbidity  was  little  affected.^ 

Castellani  has  practised  vaccination  against  bacillary 
dysentery,  mixing   anti-dysenteric  vaccine  with  anti- 

^  Animals  may  be  more  readily  vaccinated  against  the  dysentery 
bacillus  than  man.  In  mice  immunity  is  obtainable  in  40  to  50  per 
cent,  of  cases ;  there  is  first  a  phase  of  sensitiveness  as  regards  the 
viruSj  and  then  a  phase  of  immunity,  lasting  from  four  to  six  weeks 
(Dopter). 


376    DYSENTERY,  CHOLERA,  AND  TYPHUS 

cholera  or  anti-typhoid  vaccine.  This  writer  considers 
that  anti-dysenteric  vaccine  should  be  prepared  with 
several  races  of  bacilli.  Cultures  made  in  bouillon  yield 
an  extremely  painful  and  troublesome  vaccine.  He 
consequently  employs  cultures  on  agar  or  in  peptonised 
water,  sterilised  by  means  of  carbolic  acid. 

J.  D.  Thomson  has  investigated  the  same  subject  at 
the  Lister  Institute.  Anti-dysenteric  vaccine  prepared 
by  heating  or  sensitising  was  found  to  be  toxic  and 
painful.  Heating  does  not  diminish  its  toxicity,  and, 
according  to  Thomson,  destroys  its  property  of  causing 
the  formation  of  the  specific  sensitiser.  He  prefers 
vaccine  sterilised  by  carbolic  acid. 

Dean  and  Adamson  have  proposed  the  preparation 
of  a  non-toxic  heated  vaccine,  treating  it  with  equal 
parts  of  eusol  (1  in  500),  and  a  solution  of  an  alkaline 
hypochlorite ;  this  eliminates  its  toxicity  by  oxidation. 

Two  injections  of  the  bacilli  thus  treated  are  made 
(100,000,000  at  the  first  injection  ;  then,  ten  days  later, 
800,000,000;  and  a  third  injection  of  200,000,000  of 
bacilli  which  have  been  exposed  to  heat). 


ASIATIC    CHOLERA 


PART  /.—CLINICAL    SURVEY 

CHAPTER  VI  n 

SYMPTOMATOLOGY 

The  term  cholera  denotes  a  syndrome  the  principal 
characteristics  of  which  are  an  extremely  abundant 
gastro-intestinal  flux,  accompanied  by  algidity,  vomit- 
ing, and  cramps  (Asiatic  cholera,  Cholera  nostras,  Stibial 
cholera,  Cholera  infantum,  Chicken  cholera,  etc.). 

The  endemo-epidemic  malady  whose  specific  agent 
is  known  as  the  cholera  vibrio,  or,  by  reason  of  its  usual 
form,  the  ''comma  bacillus,"  will  alone  be  considered 
here. 

There  is  not  one  single  cholera  vibrio,  but  various 
races  of  cholera  vibrios,  which  possess  characteristics 
of  their  own,  and  these  characteristics  sometimes  present 
considerable  differences. 

Their  pathogenic  action  in  man  is  clinically  uniform, 
and  gives  rise  to  a  series  of  symptoms  which  may  be 
divided,  schematically,  into  four  periods  : 

1.  The  period  of  incubation. 

2.  The  initial  period,  or  period  of  invasion. 

3.  The  choleraic  period,  or  attack. 

4.  The  period  of  reaction. 

1.  The  Period  of  Incubation.  —  The  Constantinople 
Conference  adopted  the  opinion  that  this  period  does 
not,  in  the  majority  of  cases,  exceed  a  few  days.  In 
reality  its  duration  is  variable.  According  to  Thoinot, 
it  ^'aries  bet^^'een  a  minimum  (^f  a  few  hours  and  a 
maximum  of  five  or  six  days  ;  it  may,  however,  exceed 
tliis. 

377 


378    DYSENTERY,  CHOLERA,  AND  TYPHUS 

2.  The  Initial  Period,  or  Period  of  Invasion. — ^Diarrhoea 
is  the  dominant  symptom  of  the  period  of  invasion. 
In  temperate  countries  it  is  observed  in  two  cases  out 
of  three  (Guerin)  ;  in  hot  countries  it  is  rarer,  the  disease 
often  conmiencing  at  the  first  onset  with  the  choleraic 
period. 

This  diarrhoea,  known  as  premonitory  diarrhoea, 
usually  appears  at  night  (Jaccoud). 

The  stools,  faecal,  hquid,  green,  or  the  colour  of  cafe  au 
lait,  or  sometimes  simply  serous,  possess  no  particular 
characteristics.  More  or  less  abundant  and  frequent, 
they  are  accompanied  neither  by  straining  nor  tenesmus. 
The  patient  suffers  from  loss  of  appetite,  flatulence, 
borborygmi,  lassitude  and  intellectual  torpor.  The 
tongue  is  like  that  of  indigestion,  and  there  is  a 
pronounced  thirst.  Sometimes  certain  nervous  pheno- 
mena are  observed  (vertigo,  severe  headache,  palpita- 
tion, faintness,  lassitude,  and  epigastric  pains).  These 
symptoms  may  persist  for  a  few  hours  only,  or  for  as 
long  as  a  week,  or  more  usually  they  last  from  twenty- 
four  to  seventy-two  hours  (Thoinot).  They  then  sud- 
denly give  way  to  the  choleraic  period,  or  attack. 

3.  The  Choleraic  Period,  or  Attack. — The  attack  usually 
occurs  at  night.  It  comprises  two  phases,  which  are 
plainly  distinguished  from  one  another  : 

A.  The  initial  phase  of  evacuation,  the  principal 
symptoms  of  which  are  diarrhoea,  vomiting,  cramps, 
change  of  voice,  and  alteration  in  the  general  appear- 
ance of  the  sufferer. 

B.  The  algid  phase,  which  gradually  sets  in  during 
the  course  of  the  foregoing  phase,  and  which,  when  it  is 
established,  is  characterised  by  various  derangements, 
affecting  more  especially  the  production  of  heat,  the 
circulation,  respiration,  phonation,  secretion,  al^sorp- 
tion,  etc. — derangements  which  give  rise  to  the  striking 
and  characteristic  appearance  of  the  cholera  patient. 

A.  Phase  of  Evacuation,  —  Diarrhoea.  —  "Without 
diarrhoea  there  is  no  cholera  "  (Thoinot).     Yet  cases 


SYMPTOMATOLOGY  379 

have  been  recorded,  very  rarely,  it  is  true,  of  dry  cholera — 
that  is,  cases  in  which  death  occurs  with  great  rapidity, 
before  there  has  been  any  evacuation  from  the  intestine. 

If  the  attack  has  been  preceded  by  the  so-called  pre- 
monitory diarrhoea,  the  stools  immediately  assume  a 
different  aspect. 

If,  on  the  other  hand,  the  onset  occurs  without  pre- 
monitory symptorrfs,  the  intestine  is  emptied  of  its  faecal 
contents  by  two  or  three  stools,  and  the  choleraic  stools 
make  their  appearance. 

The  typical  choleraic  stools  are  serous,  liquid,  opaline, 
or  greyish  white,  resembling  whey.  They  hold  in  sus- 
pension whitish  flakes  comparable  to  grains  of  rice, 
whence  the  name  of  rice-form  or  rice-water  stools  by 
which  they  are  known. 

These  rice-like  grains  consist  of  masses  of  desquam- 
ated epithelium,  leucocytes,  and  amorphous  debris, 
resulting  from  the  necrosis  of  the  epithelial  cells,  and 
lastly  of  cholera  bacilli,  sometimes  in  enormous  numbers. 

After  centrifugalisation  the  superincumbent  liquid 
contains  a  small  proportion  of  albumin. 

Sometimes  the  alvine  evacuations  are  green  and 
bilious,  with  or  without  rice-like  grains  ;  more  rarely 
they  are  red,  sanguinolent,  and  dysenteriform  in  appear- 
ance, resembling  meat-scrapings  (Petit,  Lesage).  In 
exceptional  cases  they  may  consist  of  a  thick  mucus, 
like  a  thick  white  soup,  or  starch  paste.  Their  odour 
is  stale  or  imperceptible  ;  never  fsecaloid.  Their  reaction 
is  alkaline,  rarely  acid  (Nanu).  According  to  Lesage 
the  stools  are  at  first  alkaline,  but  may  become  neutral 
and  then  acid  if  the  disease  persists,  and  especially 
if  algidity  is  present.  They  contain  98  to  99  per  cent, 
of  water,  little  or  no  albumin,  mucin,  urea,  phosphates, 
sulphates,  etc.  They  are  rich  in  chloride  of  sodium 
and  indican.  When  pure  sulphuric  acid  is  added  to 
the  stools  they  assume  a  characteristic  red  colour,  a 
true  nitrous  reaction  revealing  the  presence  of  indol, 
known  as  the  "  cholera  red  reaction  "  (Netter). 

The  evacuations  are  very  numerous,  occurring  every 


380     DYSENTERY,  CHOLERA,  AND  TYPHUS 

ten  or  fifteen  minutes,  sometimes  even  more  frequently, 
without  tenesmus,  without  effort,  invokmtarily  in  serious 
cases.  Although  their  volume  does  not  exceed  forty 
to  fifty  centilitres  their  repetition  results  in  a  loss  of 
six  to  seven  litres  of  liquid  in  the  twenty-four  hours 
(Lorain).  The  evacuations  are  less  numerous  when  the 
cramps  become  strongly  developed  ;  they  even  dis- 
appear completely  in  serious  conditions  of  algidity. 

Vomiting. — Vomiting  is  less  constant  and  less  fre- 
quent than  the  diarrhoea  which  it  immediately  follows  ; 
it  occurs  in  nine  cases  out  of  ten.  When  it  is  not  pre- 
sent the  patient  suffers  from  nausea  and  eructations : 
alimentary  at  first,  the  vomit  becomes  bilious,  yellow- 
ish, or  porraceous,  with  an  acid  reaction. 

Occasionally  the  vomit  is  serous,  neutral,  or  alkaline, 
holding  grey  clots  in  suspension,  when  it  rather  resembles 
the  rice-water  stools.  In  this  case  it  is  known  as 
rice-water  vomit.  Sometimes  easy,  profuse,  and  emitted 
without  effort,  in  other  patients  vomiting  is,  on  the 
contrary,  difficult,  scanty,  painful,  and  even  convulsive. 
It  may  be  accompanied  by  obstinate  and  persistent 
hiccough,  and  gastric  cramps  of  varying  intensity,  which 
are  increased  by  pressure  (Gaillard,  Lesage).  These 
are  often  provoked  by  the  ingestion  of  hot  drinks, 
which  the  patient  tolerates  less  readily  than  cold  or 
iced  ones. 

By  reason  of  the  enormous  loss  of  water  which  they 
cause  the  patient,  the  diarrhoea  and  vomiting  set  up  a 
violent  and  insatiable  thirst  :  six  litres  or  more  of 
liquid  are  insufficient  to  assuage  it  (Thoinot).  For  the 
same  reason,  the  mucous  membranes  of  the  mouth  and 
tongue  become  parched  and  dry.  The  abdomen, 
usually  soft  and  yielding,  supports  palpation  without 
pain,  and  this  palpation  causes,  above  all  in  the  right 
iliac  fossa,  a  distinct  gurgling,  as  of  large  air-bubbles, 
a  true  splashing  sound  (Thoinot).  Sometimes,  how- 
ever, the  abdomen  is  painful  and  retracted.  There  is 
a  complete  absence  of  appetite,  and  the  urine  is  scanty  ; 
while  anuria  is  frequent. 


SYMPTOMATOLOGY  381 

Cramps. — The  muscular  cramps,  which  are  rarely 
absent,  may  be  observed  in  patients  whose  diarrhoea 
is  not  profuse,  and  even  before  the  appearance  of  the 
intestinal  flux  (Barth,  Babinski).  They  may  occur  in 
all  the  muscles,  even  the  diaphragm  (Colliard).  They 
appear  first  in  the  muscles  of  the  calf,  and  then  extend 
to  the  feet  and  the  hands.  In  very  serious  cases  they 
may  reach  the  face,  the  abdomen,  and  the  thorax. 
They  are  rarely  generalised.  They  are  spontaneous, 
and  provoked  by  the  slightest  exciting  cause.  Babinski 
has  shown  that  in  cases  in  which  spontaneous  cramps 
are  rare  or  lacking  (slight  cases,  during  the  abatement 
of  the  choleraic  period)  they  may  always  be  provoked 
by  the  application  of  a  current  of  electricity  frequently 
interrupted. 

The  muscles  affected  are  contracted  (Quinquand), 
hard  and  rigid,  forming  distinct  prominences  under  the 
skin.  The  pain  caused  by  these  cramps  is  usually 
violent,  and  is  sometimes  absolutely  unbearable. 

From  the  commencement  of  the  attack  the  voice 
undergoes  modifications  ;  its  timbre  changes,  and  it 
grows  shrill  and  hardly  audible  ;  the  patient's  voice 
has  "  broken  "  ;  the  face  is  emaciated  and  purplish  ; 
the  nose  is  pinched,  the  eyes  sunken,  with  rings  beneath 
them,  and  the  skin  is  dry.  The  temperature,  which, 
at  the  outset,  may  have  been  from  100°  to  102°  in  the 
rectum  and  axilla,  falls  in  a  little  while  to  98-4°,  97°, 
96°,  etc.,  in  the  axilla,  while  it  remains  stationary  in 
the  rectum.  The  patient's  extremities  grow  colder, 
and  the  diarrhoea  diminishes  or  even  disappears.  The 
algid  or  cadaveric  phase  is  now  commencing,  with  the 
various  disorders  which  accompany  it. 

B.  Algid  Phase. — Disorders  of  Heat  Regulation. — ^After 
the  slight  febrile  derangement  of  the  initial  period  hypo- 
thermia makes  its  appearance.  The  algidity  is  mani- 
fested more  particularly  in  the  region  of  the  extremities  ; 
it  is  readily  appreciable  to  the  touch.  Magendie  has 
noted  temperatures  of  64-4°  and  69-8°  at  the  feet  ; 
Lorain  has  shown  that  the  buccal  temperature  may  fall 


382      DYSENTERY,  CHOLERA,  AND  TYPHUS 

as  low  as  77°.  The  axillary  temperature  is  less  reduced  ; 
it  is  usually  between  95°  and  98*6°,  but  has  been  known 
to  fall  to  91*4°  (Lorain).  The  internal  temperature 
bears  no  relation  to  the  peripheral  temperature.  Taken 
in  the  rectum,  it  may  be  subnormal  (93-2°  Lorain ; 
89-6°,  Galliard ;  86°,  Hayem),  normal,  or  at  times 
even  febrile  (104°,  Manson ;  104-4°,  Hayem  ;  106-7°, 
Galliard).  As  death  approaches,  in  the  algid  phase,  the 
rise  of  temperature  may  rise  to  107°  or  more  in  the 
rectum  or  vagina. 

Finally,  Lesage  has  recorded  three  cases  in  which  the 
rectal  temperature  fell  from  100-4°  to  78-6°,  while  the 
axillary  temperature  rose  from  95°  to  98-9°. 

As  will  be  seen,  the  dissociation  between  the  peri- 
pheral and  internal  temperatures  of  the  cholera  patient 
is  subject  to  no  fixed  rule. 

A  survey  of  the  question  of  temperature  from  the 
standpoint  of  prognosis  may  furnish  us  with  a  few 
useful  indications.  A  buccal  temperature  lower  than 
80-6°  is  a  fatal  prognostic.  Great  differences  between 
the  rectal  and  axillary  temperatures,  and  progressive 
hypothermia  (although  this  may  not  be  very  consider- 
able, nor  very  persistent)  internal  and  external,  are  of 
evil  augury ;  while  normal  or  supernormal  temperatures 
are  of  good  augury. 

Derangements  of  the  Circulation. — ^The  pulse  is  rapid, 
usually  exceeding  100  beats  per  minute  (in  a  fatal  case 
of  Laveran's  it  was  185).  It  becomes  small  and  thread- 
like, and  may  even  disappear  completely  in  serious  cases : 
first  from  the  radial,  then  from  the  humeral,  and 
lastly  from  the  crural  and  carotid  arteries.  The 
capillary  circulation  is  interrupted  ;  there  is  a  stasis  of 
the  venous  system  and  the  arterial  system  is  unduly 
empty.  The  heart  fails  more  slowly  than  the  pulse. 
Its  sounds  become  muffled  and  remote  ;  the  first  sound 
disappears,  while  the  second  may  be  distinguished  for 
some  time  longer  (Magendie).  At  the  very  end  of  the 
algid  phase  the  ear  can  no  longer  perceive  anything 
more  than  a  deep,  confused  murmur  sometimes  masked 


SYMPTOMATOLOGY  383 

by  a  soujffle  which  is  attributed  to  the  formation  of 
intracardiac  clots  (Thoinot). 

The  blood  undergoes  profound  modifications,  Drawn 
from  the  veins  during  life  it  is  black,  thick,  sticky,  re- 
minding oncjof  currant  jelly  which  has  not  set  properly. 
Its  respiratory  capacity  is  considerably  diminished. 
The  serum  is  scanty,  and  exudes  with  difficulty ;  its 
density  is  increased,  its  specific  gravity  varying  from 
1036  to  1044  and  even  1058 ;  its  alkalinity  is  diminished 
(Hayem). 

There  is  a  relative  increase  of  organic  matter,  and 
above  all  of  albuminoids.  The  chlorides  are  diminished. 
The  urea  is  increased,  rising  as  high  as  2  grammes  '43 
per  litre,  according  to  Voigt,  and  to  3  granliiies  -60 
according  to  Chalvet,  instead  of  the  normal  maximum 
of  0  grammes  '20.  By  reducing  the  mass  of  the  blood 
to  four-fifths  of  the  normal,  cholera  produces  a  very 
great  concentration  of  the  blood  (Hayem).  This  is 
shown  by  a  very  considerable  polycythemia,  the  cubic 
millimetre  of  blood  containing  5,200,000  to  8,000,000 
red  corpuscles  (Hayem).  This  polycjrthemia  appears 
early  ;  it  commences  from  the  third  hour.  Anaemia  is 
rare.  Cholera  is  usually  acconipanied  by  an  early  hyper- 
leucocytosis,  making  its  appearance  from  the  twelfth 
hour  ;  it  varies  from  13,500  to  60,000  white  corpuscles 
per  cubic  millimetre,  reaching  its  maximum  in  the  algid 
phase,  and  diminishing  in  the  following  phase  ;  or,  on 
the  other  hand,  in  fatal  cases  it  does  not  diminish,  but 
will  even  continue  to  increase  until  death.  This  hyper- 
leucocytosis  affects  the  polymorphonuclear  leucocytes 
(64  to  88  per  cent.,  according  to  L.  Rogers).  The 
proportion  of  eosinophile  leucocytes  is  diminished  or 
remains  normal  (0*2  to  1-8  per  cent.,  according  to 
L.  Rogers). 

Derangements  of  the  Respiration  and  Phomxtion. — ^The 
cholera  patient  suffers  from  a  continual  dyspnoea,  with 
precordial  anxiety  and  a  feeling  as  of  a  bar  across  the 
stomach,  which  is  stifling  him.  This  dyspnoea  is 
characterised  by  an  increase  of  the  respiratory  rate, 


384     DYSENTERY,  CHOLERA,  AND  TYPHUS 

which  may  attain  to  fifty  or  sixty  per  minute,  and  also 
by  an  alteration  of  the  respiratory  rhytlam.  The  in- 
spiration is  prolonged,  and  it  is  not  unusual,  after  a 
forced  inspiration,  to  observe  a  pause,  followed  by  a 
sudden  expiration,  accompanied  by  a  plaintive  moan. 

This  dyspnoea  does  not  arise  from  any  pulmonary 
lesion  ;  it  is  due  to  imperfect  and  insufficient  oxidation 
of  the  blood,  and  perhaps  also  to  bulbar  excitation  due 
to  the  cholera  toxin.  It  may,  when  it  is  extreme,  cause 
the  rupture  of  a  certain  number  of  pulmonary  vesicles, 
thus  causing  emphysematous  lesions. 

The  voice  of  the  cholera  patient,  which  is  merely 
"  broken  "  in  the  phase  of  evacuation,  becomes  stifled, 
and,  in  the  majority  of  cases,  there  is  complete  aphonia 
in  the  algid  phase. 

Disorders  of  Secretion. — During  the  course  of  the 
algid  phase  of  cholera  the  biliary  secretion  is  diminished 
(H.  Violle) ;  the  lachrymal  and  sebaceous  secretions  are 
arrested.  The  lacteal  secretion  may  persist  during  the 
attack,  as  may  also  the  menstrual  flow  ;  but  one  of  the 
capital  symptoms  of  the  algid  phase  of  cholera,  and  one 
of  the  most  constant,  is  anuria  :  not  absolute  anuria, 
but  an  anuria  which  is  almost  absolute.  "  One  may  still 
manage  to  obtain  a  few  drops  of  urine,  either  by  waiting, 
or  by  searching  for  the  liquid  in  the  bladder  with  a 
catheter  "  (Lorain).  As  soon  as  an  improvement  takes 
place  the  urine  reappears.  However,  fatal  cases  have 
been  recorded  in  which  there  was  no  suppression  of  the 
urinary  secretion,  and  other  cases  in  which  patients, 
who  for  several  days  had  remained  anuric,  have  passed 
urine  a  few  moments  before  death  (pre-agonal  urina- 
tion). 

Disorders  of  Absorption. — (a)  Absorption  through  the 
mucous  membranes  of  the  digestive  organs  no  longer 
takes  place  during  the  algid  phase.  Food  and  drink 
are  vomited  intact,  or  found  intact  in  the  stomach  at 
the  autopsy.  Drugs  taken  are  without  effect,  for 
they  are  not  absorbed.  Opium,  sulphate  of  quinine, 
belladonna,  strychnine,  all  active  medicines,  with  well- 


SYMPTOMATOLOGY  385 

known  effects,  are  incapable  of  producing  any  effect 
whatever,  even  in  large  and  almost  poisonous  doses. 
Iodide  of  potassium  and  ferrocyanide  of  potassimxi 
cannot  be  detected  in  the  urine  (Thoinot).  Alcohol, 
however,  appears  to  be  absorbed  (Vigla). 

{b)  Cutaneous  and  Subcutaneous  Absorption. — "  In- 
unctions of  belladonna  in  the  axilla  (the  dose  being 
4  grammes)  do  not  dilate  the  pupils.  Bouchut,  deposit- 
ing by  incision,  in  the  subcutaneous  tissues  of  algid 
cholera  patients,  5,  10,  or  15  centigrammes  of  morphia, 
found  the  doses  unaffected  at  the  autopsy.  Isambert, 
in  1866,  injected  curare  under  the  skin ;  Grubler  in- 
jected sulphate  of  quinine,  and  Lailler  injected  atropine  ; 
they  observed  no  absorption  "  (Thoinot). 

(c)  Intravenous  Absorption. — The  absorption  of  sub- 
stances injected  directly  into  the  circ^lation  takes  place 
in  the  normal  manner. 

External  Appearances  of  the  Algid.  Cholera  Patient. — 
The  algid  cholera  patient  presents  an  appearance  which 
is  very  characteristic.  It  has  been  described  in  masterly 
fashion  by  A.  Laveran :  ''  The  sufferers,  exhausted, 
prostrated,  are  lying  on  their  backs,  their  limbs  ex- 
tended, motionless.  The  eye,  sunk  in  the  orbit,  owing 
to  the  subsidence  of  the  cellulo-adipose  cushion,  is  in- 
completely covered  by  the  eyelids,  for  of  these  the 
orbicular  lid  is  paralysed  (Graefe)  ;  dark  spots,  of  a 
blackish,  dirty  blue,  appear  on  the  surface  of  the  sclera, 
or  the  eye  is  reddened  by  the  development  of  a  keratitis. 
The  cyanosis  of  the  eyelids  deeply  outlines  the  osseous 
contour  of  the  orbit  ;  the  nose  is  peaked  ;  the  cartilagin- 
ous prominences  are  seen  through  the  parched  skin  ; 
the  lips  are  thinned,  adhering  to  the  teeth,  or  half  open  ; 
they  are  bluish  or  purple  in  hue.  The  cheeks  and 
temples  are  hollow  ;  a  livid  pallor,  or  a  swarthy,  blackish 
tint  gives  the  features  an  aspect  as  characteristic  as  it 
is  appalling,  and  when,  as  the  disease  progresses,- the 
congested,  purulent  conjunctiva,  v^and  the  wrinkled 
cornea,  desiccated  as  that  of  a  corpse,  have  robbed  the 
glance  of  all  expression  ;  when  this  withered  eye,  sunken 


386     DYSENTERY,  CHOLERA,  AND  TYPHUS 

in  its  orbit,  shows  through  half-opened  eyeKds,  it  is  per- 
missible to  say  that  death  has  beforehand  marked  the 
sufferers  with  his  seal." 

The  skin  of  the  algid  cholera  patient  presents  a 
cyanotic  tint,  the  intensity  varying  from  blackish  purple 
to  pale  purple.  This  is  sometimes  localised  at  the 
extremities  (hands,  feet,  nose,  ears),  sometimes  dis- 
seminated all  over  the  body  in  the  form  of  spots  and 
mottlings,  and  sometimes  general. 

This  is  the  cyanotic  or  blue  cholera  which  is  observed 
in  young  subjects  who  present  no  renal  or  hepatic  altera- 
tion. There  is  a  rarer  form  known  as  pallid  cholera 
(Giraud,  H.  Lespiau,  and  Guerrier),  observed  in  patients 
who  have  passed  their  fiftieth  year,  or  who  present 
lesions  which  are  principally  renal,  in  the  course  of  which 
the  algid  patient  remains  pallid  until  the  moment  of 
death,  the  moment  at  which  cyanosis  generally  makes 
its  appearance. 

The  skin  of  the  cholera  patient,  and  particularly  the 
skin  of  the  extremities,  possesses  another  very  special 
characteristic  :  it  is  withered,  wrinkled,  covered  with  a 
cold  sweat,  viscous  and  sticky,  and  gives  the  sensation 
of  touching  the  skin  of  a  batrachian. 

Sometimes  there  are  veritable  sweats  of  urea. 

More  or  less  rapidly  the  algid  cholera  patient  grows 
weaker ;  his  intelligence  becomes  lethargic,  and  he 
presently  falls  into  a  condition  of  torpor,  absolute 
physical  and  mental  torpor.  In  severe  and  sudden 
cases,  and  above  all  in  cases  of  blue  cholera,  the  patients 
are  restless  and  agitated  ;  they  constantly  turn  over 
and  over  in  bed ;  they  are  anxious ;  they  moan  and 
complain,  and  are  slightly  delirious.  Sometimes  the 
delirium  is  violent,  with  cries,  and  hallucinations  of  sight 
and  hearing. 

Convulsions  have  rarely  been  observed  at  the 
approach  of  death,  which  occurs  during  the  asphyxial 
collapse.  In  cases  of  pallid  cholera  the  patient,  calm 
and  somnolent,  dies  in  a  state  of  coma. 

The  duration  of  the  algid  phase  varies  from  a  few 


SYMPTOMATOLOGY  387 

hours  to  three  or  four  days;    its  average  duration  is 
twenty-four  hours. 

4.  The  Period  of  Reaction. — If  the  cholera  patient 
does  not  succumb  during  the  attack  he  enters  upon  a 
new  period,  called  by  medical  writers  the  period  of 
reaction,  which  leads  to  recovery  or  death. 

When  the  cholera  patient  recovers,  so  to  speak, 
at  the  first  trial,  without  complications,  the  period  of 
reaction  is  said  to  be  regular  ;  it  is  a  true  normal 
convalescence. 

Such  is  not  always,  the  case,  however  ;  and  only  too 
often  the  period  of  reaction  gives  rise  to  complications 
to  which  the  patient  succumbs. 

The  evolutionary  grouping  of  these  complications 
enables  us  to  speak  of  regular  reactions,  abortive  reactions, 
and  typhoidal  reactions. 

The  Regular  Reaction. — After  an  algid  phase  of  no 
great  severity,  slowly  and  steadily  the  patient  returns 
to  health.  His  heart  beats  more  strongly  and  regularly, 
recovering  sooner  than  the  pulse,  which  beats  more 
slowly  and  strongly  ;  and  the  peripheral  circulation  re- 
establishes itself.  The  skin  regains  its  normal  colour  ; 
it  becomes  warm  again,  first  the  skin  of  the  forehead, 
then  that  of  the  face,  then  that  of  the  neck,  the  breast, 
and  the  extremities  (Oddo)  ;  and  it  is  covered  with 
a  warm  and  abundant  perspiration.  The  respiration 
grows  calm  and  regular  ;  the  voice  recovers  little  by 
little  ;  the  temperature  regains  its  general  equilibrium. 
Absorption  through  the  mucous  membranes  of  the 
digestive  organs  and  the  skin,  suppressed  during  the 
algid  period,  reappears  in  its  normal  activity,  and  we 
sometimes  find  that  drugs  taken  during  the  algid  period, 
which  then  remained  inactive,  produce  their  normal 
effects  as  soon  as  the  reaction  occurs  ;  it  is  easy  to 
conceive  what  dangers  may  result  from  this  in  the  case 
of  toxic  drugs  administered  without  precautions  in 
dangerous  doses  during  algidity  (Thoinot). 

The  biliary,  lachrymal,  lacteal  and  other  secretions 


388    DYSENTERY,  CHOLERA,  AND  TYPHUS 

reappear.  The  chief  indication  of  the  reaction  is  the 
re-establishment  of  the  urinary  secretion.  The  urine 
first  emitted  is  rather  scanty,  turbid,  and  more  or  less 
albuminous,  while  it  is  poor  in  urea  and  in  chlorides  ; 
it  contains  bile  pigments  and  indican  ;  the  sediment  is 
composed  of  the  debris  of  the  epithelium  of  the  bladder, 
epithelial  and  hyaline  casts,  white  corpuscles,  and  some- 
times red  corpuscles. 

The  urine  of  the  second  emission  is  more  abundant 
and  more  limpid.  Very  soon  a  state  of  polyuria  sets  in, 
usually  reaching  its  maximum — when  as  much  as  eight 
litres  may  be  passed  in  the  twenty-four  hours — between 
the  fourth  and  ninth  days.  Lorain,  however,  has 
known  this  polyuria  to  cease  at  the  end  of  twenty-four 
hours,  and  in  other  cases  to  last  a  month.  This  polyuria 
seems  to  be  an  energetic  means  of  elimination. 

Urea,  uric  acid,  phosphoric  acid,  and  the  chlorides 
quickly  increase  in  quantity,  and  for  a  few  days  exceed 
the  normal.  At  the  same  time  the  urine  eliminates 
waste  products  from  the  kidneys  and  bladder  :  pus 
cells,  epithelial  cells,  red  corpuscles,  casts,  crystals  of 
oxalate  and  urate  of  lime,  etc.,  etc.  The  albumin 
which  is  constantly  present  in  the  first  specimens  quickly 
disappears,  and  as  it  does  so  there  is  often  a  temporary 
and  unimportant  appearance  of  sugar. 

When  the  reaction  proceeds  normally  it  is  apyretic, 
but  in  certain  very  rare  cases  the  patient  passes  very 
rapidly  from  algidity  to  a  veritable  circulatory  pyrexia ; 
the  temperature  rises  to  100°  to  103° ;  the  pulse  is 
bounding,  its  frequency  attaining  100  to  120  ;  the  urine 
is  febrile,  the  tongue  like  that  of  indigestion,  and 
headache  is  present.  This  condition  continues  for 
about  forty-eight  hours;  then  all  becomes  normal 
again,  and  recovery  follows. 

The  Abortive  Reaction. — Aged  persons,  or  subjects 
enfeebled  by  some  previous  cause,  physiological  or 
pathological,  are  more  often  than  not  unable  to  bear 
the  strain  of  the  reaction.  The  latter  sets  in,  but 
is    insufficient    and    abortive.      The    patient    remains 


SYMPTOMATOLOGY  389 

prostrate  and  somnolent ;  the  urinary  secretion  is 
scanty  ;  the  warmth  of  the  skin  does  not  return  in  a 
uniform  manner  ;  the  hands  are  still  cold,  while  the 
trunk  is  already  burning  ;  algidity  jnay  return,  followed 
by  a  fresh  abortive  reaction. 

The  patient  may  succumb  suddenly,  collapse  occur- 
ring after  several  fruitless  attempts  at  reaction  ;  or  he 
may  pass  into  a  typhoid^like  condition. 

The  Typhoid  State. — ^The  typhoid  state  gives  the 
patient  all  the  appearances  of  a  typhoid  patient ;  the 
face  is  dull  and  unintelligent ;  there  is  intellectual 
torpor,  and  more  or  less  violent  delirium ;  the  tongue 
is  parched  ;  there  is  diarrhoea,  vomiting,  oliguria  and 
severe  headache,  while  the  face  and  the  conjunctivae 
are  injected.  Only  the  temperature — and  herein  the 
condition  differs  from  typhoid — remains  normal  or 
nearly  so  (96-8°  to  100-4°). 

The  typhoid  state  presents  many  clinical  forms, 
among  which  we  must  mention  a  cerebral  form,  with  its 
two  varieties,  the  comatose  and  the  ataxo-adynamic, 
accordingly  as  stupor  or  delirium  predominates  (Oddo), 
and  a  gastro-intestinal  form,  the  most  frequent,  whose 
chief  symptom  is  an  obstinate,  bilious,  blood-stained 
diarrhoea,  which  may  cause  death  between  the  fifth 
and  eleventh  days,  by  internal  haemorrhage,  with 
prostration  and  hypothermia.  When  the  patient 
recovers  the  convalescence  is  always  long,  and  is  often 
attended  by  complications. 

In  the  course  of  the  typhoid  state,  and  also,  although 
more  rarely,  during  the  normal  reaction,  one  may 
observe  an  essentially  polymorphous  exanthem  recall- 
ing those  of  smallpox,  scarlatina,  papular  roseola, 
urticaria,  erythema  nodosum,  miliaria,  herpes,  purpura, 
etc.  These  eruptions  most  frequently  affect  the 
extremities,  particularly  the  forearm  and  the  wrist,  but 
may  be  generalised.  Their  duration  is  variable  ;  they 
evolve  without  fever,  or  with  slight  fever  only,  and  are 
accompanied  by  no  general  derangement ;  they  termin- 
ate in  a  more  or  less  abundant  desquamation,  according 


390    DYSENTERY,  CHOLERA,  AND  TYPHUS 

to  the  nature  of  the  case.     Their  prognostic  significa- 
tion is  said  to  be  favourable  rather  than  otherwise. 

Accidents  and  Complications 

Many  accidents  and  compUcations  may  occur  during 
the  various  phases  of  cholera.  But  it  is  more  particu- 
larly during  the  phase  of  reaction,  and  during  con- 
valescence, that  they  are  most  frequently  observed. 
The  most  important  only  need  be  mentioned. 

1.  Chronic  Diarrhoea. — ^The  intestine  of  the  cholera 
patient  remains  peculiarly  susceptible,  and  tolerates  a 
solid  diet  with  difficulty.  A  chronic  diarrhoea  may 
graft  itself  on  to  the  cholera  and  bring  the  patient  into 
a  condition  of  marasmus. 

2.  Gangrene.  —  Lesions  of  the  circulatory  system 
are  indicated  by  various  complications  :  anaemia, 
oedema,  or  myocarditis,  which  may  result  in  sudden 
death.  The  most  usual  complication  is  gangrene. 
During  the  algid  phase  one  observes  gangrene  of  a 
strictly  local  nature,  in  superficial  patches,  on  the 
nose,  the  tongue  (Gendrin),  the  ears,  the  lips  (Tardieu), 
etc.  But  during  the  period  of  convalescence  and 
reaction  one  may  meet  with  : 

(a)  Visceral  gangrene — rare,  it  is  true,  of  the  intestine 
(Bouillaud,  Mouchet,  Oddo)  and  the  lungs  (Mouchet, 
Penieres). 

(b)  Cutaneous  gangrene,  usually  subsequent  to  an 
irritation  of  the  skin  ;  applications  of  leeches,  blisters, 
sinapisms,  chloroform  ointments,  etc.  Galliard  records 
two  cases  of  sudden  and  overwhelming  septic  gangrene 
following  upon  subcutaneous  injections  of  caffeine  and 
ether. 

(c)  Gangrene  of  the  extremities,  usually  very  serious, 
due  to  arterial  obliteration,  most  frequently  throm- 
botic, but  sometimes  embolic.  This  form  of  gangrene 
usually  attacks  the  foot,  but  may  spread  over  the  whole 
of  the  lower  limb. 


SYMPTOMATOLOGY  391 

3.  Nervous  Accidents. — During  convalescence  cramps 
may  be  observed,  localised  in  the  calves,  and 
true  paroxysms  of  tetany.  These  paroxysms,  which 
are  not  particularly  frequent,  are  localised  in  the  hands 
or  feet ;  they  are  generally  brief  and  benign,  but 
occasionally  severe  and  prolonged.  The  return  of  the 
paroxysm  may  be  provoked  at  will  by  compressing  one 
of  the  large  nervous  or  vascular  trunks  of  the  part 
affected  (Trousseau's  symptom).  Localised  paralysis 
has  also  been  reported,  and  deafness.  Dementia  of  a 
long-continuing  character,  and  temporary  monomania, 
are  not  unknown. 

4.  Pulmonary  Complications. — Pneumonia  and  broncho- 
pneumonia, rare  in  hot  countries,  are  of  frequent 
occurrence  in  temperate  countries,  the  latter  disease 
being  far  more  frequent  than  the  former  (Kelsch, 
Dubreuilh,  Simmonds,  Oddo). 

Broncho-pneumonia  is  incidental,  more  particularly 
to  the  abortive  type  of  reaction ;  its  development  is 
insidious  and  apyreticj  the  temperature,  according  to 
Dubreuilh,  varying  from  91-4°  to  93*3°,  while  Galliard 
gives  it  as  92-5°  ;   it  is  always  subnormal   (Oddo). 

Pneumonia,  according  to  Oddo,  is  more  obvious  in  its 
development ;  in  default  of  shivering,  fever,  cough, 
expectoration,  and  stitch  in  the  side  may  attract 
attention. 

These  complications  are  extremely  serious,  and  the 
rapidity  of  their  development  is  surprising.  Termina- 
tion by  suppuration  is  not  infrequent,  and  gangrene  is 
not  very  uncommon. 

It  has  been  said  that  during  the  algid  phase  the 
dyspnoea  is  sometimes  so  violent  that  the  pulmonary 
vesicles  are  distended  to  the  point  of  bursting.  Usually 
emphysema  stops  at  the  level  of  the  lung,  but  Galliard 
has  recorded  a  case  in  which  the  air  invaded  the  medi- 
astinal connective  tissue,  then  the  subcutaneous  cellular 
tissue  of  the  neck,  and  finally  the  supraclavicular  region. 

5.  Jaundice.  —  This    is    a     rare    phenomenon.     Most 


392     DYSENTERY,  CHOLERA,  AND  TYPHUS 

frequently  a  toxic  jaundice  of  no  importance  is  met 
with,  but  sometimes  it  recalls  the  characteristics  of  the 
dangerous  forms  of  jaundice.  In  such  cases  we  have  to 
deal  with  an  infectious  jaundice,  caused  by  the  multiplica- 
tion of  the  cholera  vibrio  in  the  biliary  ducts  :  choleraic 
angiocholitis  and  cholecystitis  (Galliard,  Girode). 

6.  Secondary  Infections. — ^After  cholera,  as,  for  that 
matter,  after  all  infectious  maladies,  various  inflamma- 
tions and  suppurations  and  other  complications  may  be 
encountered.  These  are :  otitis,  conjunctivitis,  kerato- 
conjunctivitis, parotitis,  rhinitis,  lymphangitis,  ery- 
sipelas, boils,  phlegmon,  thrush,  pharyngeal  diphtheria, 
ecthyma,  oedema  of  the  glottis,  etc. 

Relapses,  Recurrences 

Owing  to  the  results  of  errors  in  diet,  explainable  by 
the  generally  voracious  appetite  and  the  absolutely 
inextinguishable  thirst  presented  by  the  convalescent 
cholera  patient,  and  sometimes  also  without  any 
appreciable  cause,  a  relapse  may  occur  which  re- 
establishes the  entire  series  of  choleraic  symptoms. 
In  all  epidemics  of  cholera  a  few  exceptional  cases  of 
recurrences  are  encountered. 

Clinical  Forms 

From  the  clinical  point  of  view,  cholera  presents 
itself  under  many  aspects,  varying  according  to  the 
development  of  the  disease,  the  age  of  the  patient,  and 
his  previous  physiological  or  pathological  condition  ; 
lastly,  according  to  the  particular  epidemic  under 
observation. 

A.  The  evolution  of  the  disease  permits  of  the  dis- 
tinction of  several  types. 

1.  Choleraic  Diarrhoea,  which  is  the  minimum  form  of 
the  choleraic  infection.  It  is  confined  to  the  premoni- 
tory diarrhoea  which  sometimes  precedes  the  attack. 


SYMPTOMATOLOGY  ,393 

It  is  difficult  to  distinguish  it,  clinically,  from  simple 
diarrhoea.  Accordingly,  in  time  of  epidemic,  any  case 
of  diarrhoea  must  be  regarded  as  suspect,  and  the 
bacteriological  diagnosis  of  its  nature  duly  established. 
Choleraic  diarrhoea  continues  for  a  few  days  only  and 
ends  in  recovery. 

2.  Cholerine  represents  a  higher  degree  of  choleraic 
intoxication.  It  commences  suddenly  in  the  middle  of 
the  night,  with  diarrhoea,  accompanied  by  vomiting, 
cramps  in  the  calves,  severe  headache,  and  intense  thirst. 
There  are  signs  of  algidity  ;  the  pulse  grows  weak  ;  the 
urine  becomes  scanty.  Cholerine  may  terminate  in 
recovery  in  a  few  days,  but  recurrences  are  common 
if  the  slightest  error  of  diet  is  committed. 

3.  Cholera. — A  great  many  classifications  have  been 
proposed  for  the  purpose  of  grouping  the  multiform 
dinical  aspects  of  cholera.  A  simple  clinical  division 
into  the  slight  form,  the  severe  form,  and  the  foudroyant 
or  sudden  and  overwhelming  form  is  sufficient. 

(a)  The  Slight  Form. — Characterised,  apart  from  the 
diarrhoea,  by  the  persistence  of  the  radial  pulse,  and  of 
the  urinary  secretion,  which  may  be  diminished,  but  is 
never  completely  suppressed,  and  by  a  barely  percep- 
tible cyanosis  and  collapse. 

(h)  The  Severe  Form. — This  is  marked  by  the  strongly 
marked  symptoms  of  cholera  already  described : 
aphonia,  vomiting,  diarrhoea,  algidity,  pulse  nearly  or 
quite  imperceptible,  absolute  anuria,  and  the  choleraic 
habitus.  The  reaction  is  most  frequently  of  the 
typhoidal  type. 

(c)  The  Foudroyant  Form. — In  certain  exotic  epi- 
demics the  patients  die  in  a  few  hours,  in  a  few  moments, 
as  though  shot  or  struck  by  lightning.  In  our  country 
this  foudroyant  form,  which  is  often  observed  in  the 
first  cases  of  an  epidemic,  is  less  alarming.  Death 
occurs  in  three  to  twenty-four  hours  (Thoinot). 

B.  Cholera  affected  by  the  Age  of  the  Patient. — Newly 
born  infants  fed  at  the  breast  usually  escape  cholera. 


394    DYSENTERY,  CHOLERA,  AND  TYPHUS 

In  children  the  progress  of  the  disease  is  rapid,  the 
evacuations  profuse,  the  vomiting  inconstant,  while 
cramps  are  rare.  The  child  quickly  falls  into  a  state  of 
coma  and  algidity.  The  period  of  reaction  is  particu- 
larly rich  in  nervous  phenomena  (Thoinot). 

The  aged  are  often  carried  off  by  foudroyant  cholera. 
Adynamia  predominates  ;  the  algid  phase  is  abnor- 
mally prolonged,  and  when  the  reaction  sets  in  it  is  more 
often  than  not  abortive.  Convalescence  is  often  re- 
tarded by  gangrenous  or  suppurative  complications 
(eschars),  pulmonary  or  intestinal. 

C.  Cholera  as  affecting  the  Physiological  Conditions  of 
Woman. — Menstruation  may  persist  during  algidity. 
If  the  menses  are  suspended  during  this  period,  they 
may  reappear  at  the  moment  of  reaction. 

Pregnant  women  escape  abortion  only  if  attacked  by 
the  slight  form  of  cholera  (Galliard).  In  at  least  fifty 
per  cent,  of  cases  cholera  causes  abortion,  and  it  kills 
women  who  do  not  miscarry  even  more  frequently  than 
those  in  whom  it  causes  the  expulsion  of  the  foetus 
(Thoinot). 

The  expulsion  of  the  foetus  occurs  during  the  period 
of  reaction  (Lorain).  The  child" is  usually  still-born,  or 
succumbs  shortly  after  birth.  The  death  of  the  foetus 
always  precedes  that  of  the  mother,  whence  the  futility 
of  a  post-mortem  Caesarian  operation  (Galliard). 
Cholera  almost  invariably  causes  the  death  of  women 
who  have  recently  been  delivered. 

In  wet-nurses  the  lacteal  secretion  may  fail  during 
the  attack,  but  upon  reaction  it  returns  in  great 
abundance.  Sometimes  it  is  unaffected,  and  the 
breasts  may  even  become  gorged  with  milk,  until 
artificial  extraction  becomes  necessary  (Magendie,  Oddo, 
Galliard). 

D.  Cholera  as  affected  by  the  Pathological  Condition. — 
Generally  speaking,  anterior  maladies  are  suspended  by 
cholera  ;  when  the  cholera  disappears  they  return,  com- 
pleting their  course  if  acute,  and  prolonging  it  if  chronic. 

Bronchitis,  pneumonia,  acute  articular  rheumatism, 


SYMPTOMATOLOGY  395 

whooping-cough  and  diabetes  cease  at  the  moment  of 
the  attack,  to  reappear  after  recovery. 

The  association  of  cholera  and  typhoid  fever  is  one 
of  extreme  gravity.  The  case  is  equally  serious  when 
cholera  attacks  a  malarial  patient  during  an  access  of 
fever. 

In  tubercular  cases  the  pulmonary  troubles  shrink  to 
a  minimum,  but  if  the  patient  survives  the  attack  the 
tuberculosis  becomes  exacerbated  and  quickly  carries 
the  patient  off  (Briquet  and  Mignot). 

Pleuritic  effusions,  and  the  serous  or  subcutaneous 
effusions  of  Bright's  disease,  of  cardiac  affections,  and 
of  cirrhosis  are  almost  instantaneously  swept  away  by 
the  diarrhoeal  flux,  but  the  attack  is  almost  invariably 
fatal  to  the  sufferer. 

E.  Cholera  varies  in  different  Epidemics.  —  The 
general  physiognomy  of  the  choleraic  attack  varies 
from  one  epidemic  to  another.  In  one  epidemic  diges- 
tive symptoms  predominate ;  in  another  the  algid 
symptoms  ;  in  a  third  cyanosis  is  the  most  prominent 
manifestation.  The  same  is  true  of  the  modes  of 
reaction. 

Certain  epidemics,  such  as  that  of  Lisbon,  have  been 
marked  by  the  extreme  benignity  of  the  cases. 


CHAPTER  IX 

DIAGNOSIS 

During  the  course  of  an  epidemic,  the  rice-water 
diarrhoea  and  vomiting,  the  cramps,  cyanosis,  the 
broken  voice,  anuria,  algidity  and  the  pecuHar 
facial  aspect  of  the  cholera  patient,  constitute  a 
body  of  symptoms  which  render  diagnosis  an  easy 
matter. 

But  this  is  not  the  case  at  the  commencement  of  an 
epidemic,  or  when  the  cases  are  sporadic  ;  the  clinical 
diagnosis  of  cholera  may  then  present  great  difficulties, 
for  a  certain  number  of  pathological  conditions  present 
choleriform  symptoms. 

Various  acute  forms  of  poisoning — viz.  tartar  emetic 
and  arsenic — bear  such  a  resemblance  to  Asiatic  cholera 
that  they  have  been  described  as  stibial,  or  antimonial 
cholera,  and  arsenical  cholera.  In  these  forms  of  poison- 
ing vomiting  precedes  the  alvine  evacuations,  which 
are  never  rice-water.  In  very  acute  arsenical  poisoning 
the  patient  experiences  a  burning  sensation  in  the 
mouth,  and  a  pricking  in  the  throat,  with  a  pronounced 
metallic  taste.  In  poisoning  by  tartar  emetic  the 
sufferer  experiences  a  sensation  of  burning  heat  in  the 
throat,  which  extends  all  the  way  down  the  oesophagus 
as  far  as  the  stomach. 

In  cases  of  poisoning  by  poisonous  fungi  there  is  rice- 
water  diarrhoea,  vomiting,  slowing  of  the  pulse,  and 
algidity  ;  but  there  are  also  constant  nervous  symptoms, 
myosis,  amblyopia,  and  occasionally  strabismus,  and 
paralysis  of  accommodation.  The  interrogation  of  the 
patient  and  those  about  him  will  direct  attention  to  the 
cause  of  the  poisoning. 

396 


DIAGNOSIS  397 

Various  forms  of  poisoning  due  to  decomposing  food 
(meat,  fish,  molluscs,  etc.)  may  give  rise  to  gastro- 
intestinal symptoms  simulating  typhoid  fever,  dysen- 
tery, or  cholera.  Diagnosis  is  sometimes  extremely 
difficult,  even  when  aided  by  bacteriological  investiga- 
tions. 

Further,  infections  due  to  the  paratyphoid  bacilli, 
and  to  Gaertner's  bacillus  in  particular,  often  closely 
simulate  infection  by  the  cholera  vibrio. 

The  pernicious  algid  access  of  malarial  origin  is  closely 
reminiscent  of  the  onset  of  cholera.  But  it  is  preceded 
by  fever,  or  comes  on  in  the  midst  of  an  attack,  and 
the  algidity  lasts  ten  or  twelve  hours  at  most,  never  a 
whole  day.  The  vomit  always  remains  bilious  and 
greenish  ;  the. stools  are  never  rice-water  ;  the  reaction 
is  followed  by  a  sudoral  crisis  which  does  not  occur  in 
cholera.  Quinine  is  efficacious.  Lastly,  examination 
of  the  blood  enables  the  physician  to  discover  large 
numbers  of  malarial  parasites. 

Certain  serious  forms  of  indigestion,  certain  forms  of 
peritonitis  of  varying  origin,  and  intestinal  obstructions 
of  a  medical  or  surgical  order  may  also  make  the  diag- 
nostician hesitate. 

Lastly,  it  is  necessary  to  establish  the  exact  nature  of 
the  first  cases  of  cholera.  In  the  so-called  cholera 
nostras  the  evacuations  are  usually  bilious  or  serous. 
The  disease  occurs  in  summer  and  autumn.  From  the 
parasitical  point  of  view  it  may  be  caused  either  by  the 
cholera  vibrio,  or  by  a  large  number  of  bacteria,  the 
paratyphoid  bacilli,  B.  coli,  etc. 

The  reader  will  perceive  the  importance  which 
attaches  to  the  determination  of  the  causative  agent  of 
a  choleriform  pathological  condition.  Only  laboratory 
research  can  give  exact  information  as  to  the  presence 
or  absence  of  the  cholera  vibrio. 

In  the  living  cholera  patient  the  vibrio  is  found  only 
in  the  stools.  It  has  also  been  discovered  in  the  vomit. 
Its  presence  in  the  blood  (Tizzoni  and  Catacci)  and  in 
the  sputum  (Mills)  should  not  be  admitted  unless  con- 


398     DYSENTERY,  CHOLERA,  AND  TYPHUS 

firmed  by  further  research.^  At  the  autopsy  it  is  to  be 
sought  only  in  the  intestine  :  in  the  rice-water  liquid 
and  grains,  and  the  exudate  which  lines  the  intestinal 
walls.  If  it  exists  it  will  certainly  be  found  there,  and 
especially  in  the  small  intestine. 

The  bacteriological  diagnosis  of  cholera  necessitates 
several  tests  :  (1)  the  cholera  vibrio  must  be  discovered 
and  isolated  ;   (2)  the  vibrio  must  be  identified. 

1.  Search  and  Isolation. — ^A  rice-like  grain  is  taken, 
or  in  default  of  this  a  drop  of  a  liquid  stool ;  it 
is  spread  out  on  a  glass  slide,  and  after  fixation  and 
staining  by  Gram's  method,  followed  by  a  double 
staining  by  fuchsine  (1  in  5),  search  is  made  for  the 
incurved  rose-coloured  bacillus  which  presents  the 
morphological  characteristics  of  the  cholera  vibrio. 
In  recent  and  typical  cases  these  vibrios  may  be  found 
in  pure  cultures  ;  in  other  cases  they  are  comparatively 
rare,  in  the  midst  of  a  varied  and  very  abundant  in- 
testinal flora.  Cultures  must  always  be  resorted  to, 
together  with  biological  tests  in  order  to  identify  the 
suspected  germ. 

The  cholera  vibrio  being  strongly  aerobic,  it  should 
be  sown  in  wide-riaouthed  flasks  or  tubes.  The  media 
of  culture  employed  are  alkaline,  and  but  slightly 
nutritive.  The  simplest  medium  is  peptonised  water, 
prepared  according  to  the  following  formula  : — 

Peptone  .  .  .  .  .  .1  gramme 

Sodium  chloride        .  .  .  ,  .     0  gr,  '50 

Water  .  .  .  .  .  .100  cc. 

After  a  few  hours  in  the  incubator  at  a  temperature 
of  37°  C.  a  turbidity  is  produced  in  this  medium,  and 
a  slight  film  forms  on  the  surface,  this  consisting  of 
various  microbes,  but  principally  of  the  cholera  vibrios. 
A  portion  of  this  film  is  re- sown  in  peptonised  water  in 
a  second  tube,  and  from  this  a  third  tube  is  sown  with 

*  Greig  has  recently  described  cholera  vibrios  in  the  lungs  and  other 
viscera.  They  seem  to  be  specially  frequent  in  the  pneumonic  con- 
ditions associated  with  the  disease. — Ed. 


DIAGNOSIS  399 

the  germ,  at  intervals  of  six  hours.  After  the  third 
transference  the  microbic  film  contains  a  very  large 
quantity  of  cholera  vibrios,  but  scarcely  any  other 
germs. 

Metchnikoff  obtains  the  same  result,  by  adding  2 
per  cent,  of  gelatine  to  the  usual  peptonised  water. 

Ottolenghi  employs  ox  bile  as  a  concentrating  medium; 
in  this  the  intestinal  germs  other  than  the  cholera  vibrio 
do  not  develop,  or  develop  only  with  difficulty.  This 
is  his  formula  ; 

Carbonate  of  sodium,  crystals  (10  per  cent;).  .     3  cc. 

Nitrate  of  potassium    .  .  .  .  .    0  gr.   10 

Fresh  ox  bile,  filtered  through  filter-paper    .  .     100  cc. 

U.  Massi  sows  the  stools  in  a  mixture  of  1  centigramme 
to  1-5  centigrammes  of  ascitic  fluid  and  4  centigrammes 
of  sterilised  water.  In  this  medium  the  atypical  cholera 
vibrio  is  said  always  to  attain  its  characteristic  form. 

Whatever  the  concentrating  or  enriching  medium 
employed,  the  physician  must  always  proceed  to  isolate 
the  cholera  vibrio.  The  best  method  is  to  sow  a  particle 
of  the  film  obtained  from  the  surface  of  one  of  the  liquid 
media  already  described  on  Dieudonne's  agar. 

The  following  is  the  method  by  which  this  agar  is 
prepared  : — A  mixture  is  made  of  equal  portions  of  de- 
fibrinated  bullock's  blood  and  a  normal  lye  of  potassium 
(56  per  1000)  ;  it  is  kept  at  boiling-point  for  half-an- 
hour.  Three  parts  of  this  mixture  are  added  to  seven 
parts  of  ordinary  agar  (3  per  100),  neutral  to  litmus. 
The  resulting  mixture  is  poured  into  some  Petri  dishes, 
which  are  left  for  twenty-four  hours  in  the  incubator, 
at  a  temperature  of  37°  C.  (98-4°  F.),  or  for  forty-eight 
hours  at  the  temperature  of  the  laboratory.  The 
cultivations  are  made  on  the  surface  ;  the  medium 
becomes  useless  five  or  six  days  after  preparation. 

Pilon  replaces  the  potash  lye  by  a  solution  of  sodium 
carbonate  (NagCog),  thus  obtaining  a  medium  which 
possesses  the  advantage  that  it  can  be  employed 
immediately. 


400    DYSENTERY,  CHOLERA,  AND  TYPHUS 

On  Dieudonne's  medium  the  colonies  of  vibrios  are 
clearly  defined  about  the  eighth  or  tenth  hour.  The 
germs  of  each  isolated  colony  are  then  identified.  This 
identification  necessitates  a  certain  number  of  cultures 
on  ordinary  agar. 

2.  Identification. — In  order  that  one  may  conclude 
that  a  given  vibrio  is  the  true  cholera  vibrio,  the 
criteria  furnished  by  the  following  tests  should  agree. 

(a)  Microscopic  Examination. — By  this  we  determine 
the  morphological  characters  of  the  bacillus,  its  motility 
and  the  existence  of  flagella. 

(b)  The  Appearance  of  the  Cultures  on  Gelatine. — Stab 
Cultures. — ^At  20°  C,  from  the  twentieth  hour,  small 
irregular  colonies  appear.  A  small  bubble  is  quickly 
formed  at  the  surface,  this  holding  an  air-bubble. 
Liquefaction  becomes  more  pronounced  ;  it  progresses 
funnel-wise,  being  more  marked  at  the  surface  than  at 
the  bottom  of  the  tube.  The  air-bubble  at  the  surface 
continues  to  exist  until  the  second,  third,  or  fourth  day. 
This  is  a  characteristic  culture  (but  this  character  is  not 
constant).  The  liquefaction  progressively  invades  the 
whole  of  the  culture-tube,  always  funnel- wise. 

On  gelatine  plates  the  isolated  colonies,  at  20°  C,  after 
twenty  or  twenty-four  hours,  are  small,  whitish  and 
transparent.  At  the  end  of  forty-eight  hours  the  gela- 
tine begins  to  liquefy  round  them,  a  little  cup  of  lique- 
faction forming.  The  colonies  then  show  a  granular 
centre,  surrounded  by  a  ring,  which  is  also  granular,  but 
wavy  in  outline.  Around  this  ring  is  a  third,  which  is 
formed  by  the  zone  of  liquefaction,  which  enlarges  daily 
until  it  invades  the  whole  plate. 

(c)  Test  for  the  Nitrous-indol  Reaction. — This  reaction 
is  obtained  by  adding  1  to  2  centigrammes  of  pure 
hydrochloric  or  sulphuric  acid  to  a  twenty-four- 
hour  culture  in  peptonised  water,  at  37°  C.  The 
reaction  is  more  visible  if  a  small  quantity  of  nitrite  of 
potassiimi  is  added  to  the  peptonised  water  (0  gramme 
•10  per  100). 


DIAGNOSIS  401 

{d)  The  Agglutination  Test  with  Experimental  Serums. 
— This  agglutination  is  rather  inconstant.  There  are 
vibrios  which  are  definitely  sensitive  to  agglutination, 
but  there  are  others  which  are  only  slightly  agglutin- 
able.  Others  again  are  agglutinable  only  after  being 
passed  through  several  culture  media. 

(e)  Inoculation. — The  intraperitoneal  injection  of 
cultures  of  cholera  bacilli  rapidly  causes  the  death  of 
guinea-pigs  from  peritonitis,  with  the  collection  of  an 
enormous  quantity  of  motile  bacilli  in  the  peritoneal 
exudate.  If  the  injection  is  made  into  the  peritoneum 
of  a  guinea-pig  which  has  been  highly  immunised,  the 
vibrios  become  immobile,  spherical,  and  granular.  The 
same  thing  is  observed  if  one  injects  into  an  ordinary 
guinea-pig  a  mixture  of  culture  and  active  anti- 
choleraic  serum.  In  vitro  Metchnikoff  and  Bordet  have 
obtained  the  same  results  by  mixing  in  sterile  test-tubes 
a  diluted  anti-choleraic  serum,  a  few  drops  of  fresh 
serum  from  a  guinea-pig  (alexin),  and  the  microbic 
emulsion. 

The  majority  of  these  characteristics  are  somewhat 
inconstant.  The  best  test  for  the  cholera  vibrio  is, 
perhaps,  to  cause  it  to  be  ingested  by  young  rabbits, 
either  by  itself  or  together  with  microbes  which  are 
favourable  to  its  development  (Metchnikoff).  Of 
the  various  laboratory  tests  employed  with  a  view 
to  diagnosing  Asiatic  cholera,  the  sero- diagnosis  of 
Achard  and  Bensaude  and  the  fixation  of  the  comple- 
ment may  be  mentioned  here.  It  does  not  as  yet 
appear,  however,  that  these  tests  can  advantageously 
replace  the  bacteriological  examinations  of  the  stool. 


CHAPTER    X 

TREATMENT 

We  have  as  yet  no  real  specific  treatment  for 
cholera.  The  experiments  in  serotherapy  made  up  to 
the  present  do  not  appear  to  be  conclusive.  Spiro 
Livieriato  claims,  however,  to  have  obtained  satis- 
factory results  by  this  method  during  the  Grgeco-Bulgar 
War  of  1915  ;  including  less  frequent  vomiting,  mitiga- 
tion of  the  cramps,  improvement  of  the  pulse,  and 
palliation  of  the  dyspnoea,  the  cyanosis,  and  the  algidity. 

Practically  the  only  method  of  treatment  which 
is  of  recognised  value  in  cholera  is  the  expectant  and 
symptomatic  one  (Sir  Patrick  Manson).  The  first 
duty  to  be  discharged  is  to  deal  energetically  with  all 
cases  of  diarrhoea  occurring  during  the  course  of  an 
epidemic.  All  varieties  of  diarrhoeal  remedies  have 
been  employed,  with  or  without  results :  opium, 
paregoric  elixir,  laudanum,  with  or  without  the  addition 
of  the  sub-nitrate  and  the  salicylate  of  bismuth,  lactic 
acid,  calomel  (in  massive  doses  of  5  to  20  centigrammes 
and  more  every  two  hours,  until  the  stools  change 
colour),  saturated  chloroform  water,  a  mixture  of  lime, 
catechu,  and  opium,  etc.,  etc. 

In  England  and  America  a  remedy  known  as  chloro- 
dyne  is  much  in  favour.  It  is  given  in  doses  of  four  to 
twenty  drops.  It  is  said  to  be  an  excellent  preparation, 
but  only  in  cases  of  premonitory  diarrhoea  (Navarre, 
Soulier). 

The  English  formulae  differ  as  to  the  composition  of 
this  remedy.  The  product  obtained  by  these  formulae 
sometimes,  in  course  of  time,  throws  down  a  precipitate, 
or  even  turns  into  a  solid  mass,  which  is  useless,  the 

402 


TREATMENT 


403 


remedy  being  administered  in  drops.  The  following 
formula,  given  by  A.  Manslau,  gives  a  stable  product 
which  keeps  well : 


Morphine  hydrochloride 

0  gr.  -50 

Chloroform         .... 

12  grammes 

Alcohol  (90  per  cent.)  • 

12 

Treacle  ..... 

.     q.s.  to  60  cc 

Fluid  extract  of  liquorice 

3  CO. 

Atropine  sulphate 

Ogr.  -05 

Essence  of  peppermint 

4  drops 

Cherry-laurel  water 

10  cc. 

Mix  the  chloroform,  alcohol,  and  essence  of  pepper- 
mint in  a  60 -cc.  flask.  Dissolve  the  morphine  and 
atropine  sulphate  in  the  cherry-laurel  water,  add  half 
the  treacle  and  the  fluid  extract  of  liquorice  in  a 
mortar,  mix,  and  make  up  to  60  cc.  with  the  treacle. 
Shaken  before  using. 

Various  antiseptic  medicaments  which  have  been 
recommended  have  not  responded  to  the  hopes  which 
were  founded  upon  them.  Such  are  salol,  iodoform, 
benzonaphthol,  naphthaline,  hydrochloric  and  sulphuric 
acid  "lemonades,"  creosol,  creosote,  chlorinated  water, 
creolin,  potassium  permanganate,  etc. 

Vomiting  may  be  relieved  by  means  of  seltzer  water, 
chloroform  water,  iced  champagne,  ice  in  small  frag- 
ments, Riviere's  draught,  etc.  The  patient  should 
retain  a  horizontal  position,  and  should  drink  only  a 
little  at  a  time,  as  copious  drinking  usually  provokes 
vomiting. 

The  beverages  most  readily  tolerated  are  the 
"  lemonades,"  made  with  tartaric  or  citric  acid. 

Irrigations  of  the  stomach,  with  boiled  water,  plain, 
or  containing  5  per  cent,  lactic  acid,  and  repeated 
five  or  six  or  seven  times  a  day,  recommended  by 
Hayem,  Delpeuch,  and  Lesage,  are  disagreeable  to  the 
patient,  and  serve  to  calm  him  only  for  a  short  time. 

The  cramps  are  relieved  by  light  friction,  dry,  or 
moist,  with  flannel  soaked  in  essence  of  turpentine  or 
camphorated    alcohol;    by   hypodermic   injections   of 


404      DYSENTERY,  CHOLERA,  AND  TYPHUS 

morphia  ;  or,  if  these  means  fail,  by  brief  inhalations  of 
chloroform. 

In  cases  of  asphyjcia  Cuneo  (of  Toulon)  has  success- 
fully employed  inhalations  of  oxygen. 

To  relieve  algidity,  hot  bricks  have  been  used;  also 
hot-water  bottles,  and  warm  baths  (102°  ^to  106°  F.). 
These  warm  baths,  of  twenty  minutes'  duration,  re- 
peated every  two  or  three  hours,  are  excellent  in  cases 
of  average  severity..  They  cause  a  rise  of  temperature 
of  2°  to  4°,  improve  the  pulse,  moderate  or  banish  the 
cramps,  and  favour  the  secretion  of  urine  (Hayem, 
Lesage,  Siredey,  Delpeuch).  Semmola  gives  vapour 
baths,  by  means  of  special  appliances,  the  patient 
remaining  in  bed.  Injections  of  caffeine  and  ether  have 
also  been  employed. 

The  rational  treatment,  however,  is  that  which  consists 
in  restoring  to  the  organism  a  portion  of  the  liquid 
which  it  has  lost,  thereby  restoring  to  the  blood  the 
amount  of  serum  which  it  requires  in  order  to  once  more 
become  sufficiently  fluid  to  circulate. 

As  early  as  1830  the  Russian  peasants  had  conceived 
the  idea  of  gorging  cholera  patients  with  saline  water. 
In  1832,  in  Scotland,  Latta  made  them  drink  enormous 
quantities  of  saline  water.  At  the  same  time  he  gave 
them  enemas  of  a  saline  solution,  and  even  injected  it 
into  their  veins. 

At  the  present  time,  according  to  circumstances  one  of 
the  following  methods  of  treatment  may  be  employed  :■ — 

1.  Enteroclysis. — Cantani  used  to  make  two  litres  of 
lukewarm  liquid  penetrate  as  far  as  possible  up  the  large 
intestine.  Lesage,  Tipiakov,  and  Bourcy  have  obtained 
good  results  with  this  method. 

Bourcy  injected  from  two  to  six  litres  of  boiled  water  ; 
cases  of  average  intensity  appeared  to  him  to  be  greatly 
improved  by  this  treatment.  One  per  cent,  tannin 
may  be  added  to  the  liquid. 

2.  Hyperdertnoclysis.  —  Subcutaneous  injections  of 
artificial   serum,  the  dose   varying  from   300   to    600 


TREATMENT  405 

grammes,  may  be  employed  in  eases  of  mediimi  inten- 
sity, when  the  circulation  is  not  interrupted. 

The  injections  are  made  under  the  skin  of  the 
abdomen  or  the  buttock.     They  may  be  repeated. 

3.  Venous  Transfusion.  —  The  liquid  employed  is 
usually  the  solution  reconmiended  by  Hayem  : 

Sodium  chloride  (pure) ....  5  grammes 

Sodium  sulphate  .  .  .  .         10        ,, 

Water     ......     1000  cc. 

The  greatest  advantage  is  derived  from  the  employ- 
ment of  serum  containing  adrenaline. 

Other  writers  employ  a  solution  of  6  parts  of  sodium 
chloride  in  1000  parts  of  water,  sometimes  adding  a 
small  quantity  of  alcohol,  but  no  sulphate  of  sodium. 

Leonard  Rogers  treated  1000  cases  of  cholera  with 
only  3*4  per  cent,  of  deaths  by  intravenous  injections 
of  hypertonic  saline  : 

Sodium  chloride  (pure)      .  .  .  .8  grammes 

Sodium  bicarbonate  .  .  .  .     20        ,, 

Water         ......     1000  cc. 

At  the  same  time  he  administered  potassium  per- 
manganate internally. 

Sir  Patrick  Manson  gives  the  following  formula  : — 

Sodium  chloride    .  .  .  .  .     3"5  grammes 

Sodium  carbonate  .  .  .  .     3*5         ,, 

Boiled  water         .  .  .  .  .1  litre 

One  or  two  litres  of  this  solution  is  injected  slowly 
and  under  slight  pressure,  at  a  temperature  of  98-4°  to 
99-4°,  into  a  vein  of  the  arm  or  leg.  The  saphenous 
vein  is  particularly  convenient. 

In  the  most  favourable  cases  intravenous  injections 
positively  resuscitate  the  patient,  and  cause  him 
straightway  to  enter  upon  the  period  of  reaction,  re- 
establishing the  circulation,  arresting  the  diarrhoea,  and 
restoring  the  urinary  secretion.     Thoinot  has  described 


406     DYSENTERY,  CHOLERA,  AND  TYPHUS 

this  effect  as  resembling  the  galvanisation  of  a  corpse, 
hut  too  often  the  recovery  lasts  only  a  few  hours.  Fresh 
transfusions  may  be  resorted  to,  if  the  algidity  returns  ; 
as  many  as  two,  four,  five,  and  even  twelve  injections 
having  been  administered  to  the  same  patient  (Lesage), 
At  the  present  time  this  method  is  in  current  employ- 
ment, and  is  not  reserved  only  for  cases  in  extremis. 

In  Hayem's  hands  it  has  yielded  30  per  cent,  of 
recoveries  ;  in  Galliard's,  29  per  cent.  It  has  therefore 
stood  the  test  of  experience,  and,  according  to  Hayem 
himself,  "  transfusion  should  be  regarded  as  a  regular 
method  of  treatment,  not  as  an  exceptional  method." 

During  the  period  of  reaction,  if  the  diarrhoea  per- 
sists, opium  and  bismuth  may  be  employed.  Under 
these  circumstances  one  may  inject  into  the  rectum,  ac- 
cording to  Sir  Patrick  Manson,  the  following  solution : — 

Tannin         .  .  .  .  .  .30  grammes 

Gum  arable  .  .  .  .  .     30        ,, 

Warm  water  .  .  .  .  .1  litre 

Constipation  should  be  treated  by  means  of  enemas, 
never  by  purgatives. 

If  the  urinary  secretion  is  not  rapidly  re-established 
large  hot  poultices  must  be  applied  to  the  lumbar  region, 
or  dry-cupping  may  be  employed ;  gentle  diuretics 
should  Jbe  used  with  great  precaution,  and  not  the 
active  ones,  which  are  unsafe.  In  convalescents  the 
diet  should  for  some  time  be  of  the  simplest  :  milk  and 
water,  barley-water  or  rice-water,  thin  soups,  vegetable 
soups,  meat-juice,  etc. 


PART  //.—EPIDEMIOLOGY   AND 
PROPHYLAXIS   OF   CHOLERA 

CHAPTER  XI 

HISTORICAL 

It  was  only  in  1830  that  cholera  made  its  appearance 
in  Europe.  But  from  time  immemorial,  before  it  over- 
flowed its  accustomed  limits,  cholera  had  prevailed,  in 
the  epidemic  or  endemic  state,  in  the  valleys  of  the 
Ganges,  the  Brahmaputra,  the  Nerbudda,  and  the  Tapty. 
The  entire  coast  of  the  Bay  of  Bengal,  Malabar,  Sumatra, 
and  Cambodia  have  been  the  classical  homes  of  cholera. 
The  arrival  in  these  regions  of  European  conquerors, 
colonists  and  manufacturers  merely  increased  the  spread 
of  epidemics,  by  bringing  them  fresh  aliment.  The 
conquest  of  India  was  marked  by  murderous  losses  ; 
soldiers,  camp-followers,  etc.,  falling  by  thousands  in  a 
few  hours  (Graves). 

It  was  in  and  after  the  year  1818  that  cholera 
spread  beyond  its  original  home,  gaining  firstly  other 
Asiatic  countries,  then  the  Philippines,  Mauritius, 
and  the  lie  du  Bourbon.  Persia,  Arabia,  and  Syria 
were  soon  to  become  the  intermediate  countries  across 
which  the  scourge  was  to  spread,  in  a  manner  that  was 
almost  periodic,  as  far  as  Russia,  whence  it  found  its 
way  into  the  other  countries  of  Europe.  From  1830 
to  1869  it  seemed  as  though  cholera,  before  overflowing 
the  continent  of  Europe  in  formidable  incursions,  was 
drawing  fresh  energies  from  India.  From  that  year 
the  disease  has  become  naturalised  in  Europe,  and  was 
responsible  for  terrible  episodes,  such  as  those  which 
marked  the  Crimean  War,  when  the  mortality  was  so 

407 


408     DYSENTERY,  CHOLERA,  AND  TYPHUS 

high  among  the  French  soldiers  and  sailors  (Fauvel, 
Scrive).  Sometimes  it  has  been  possible  to  trace  the 
manner  in  which  the  disease  has  been  transported  by 
Arabs  qr  Egyptians  travelling  from  infected  countries, 
but  in  reality  the  disease  has  become  autocthonous, 
and  if  it  no  longer  displays  the  powers  of  extension 
which  it  manifested  during  the  last  century,  it  none 
the  less  remains  a  terrible  scourge  unless  a  rigorous 
prophylaxis  is  applied. 

To  give  an  example  of  the  disastrous  severity  of 
cholera,  we  may  recall  the  epidemic  which  in  October, 
1859,  attacked  the  two  army  divisions  of  General  Martim- 
prey,  who  was  operating  in  the  province  of  Oran.  In 
a  few  days  more  than  3000  men  succumbed  to  cholera. 

The  menace  of  cholera,  moreover,  is  always  existent ; 
and  the  military  relations  which  are  being  established 
between  the  East  and  the  West  have  been  and  may 
again  become  the  reason  of  a  fresh  appearance  of  the 
disease.  There  are  few  countries  which  have  escaped 
cholera  :  the  Faroe  Islands,  the  north  of  Russia,  and 
Siberia,  a  few  islands  in  the  Pacific  Ocean,  Terra  del 
Fuego,  the  island  of  Nossi-Be  in  1870,  etc.  This  im- 
munity is  due  to  the  geographical  conditions  of  these 
regions,  which  isolate  them  and  protect  them  against 
travellers  and  the  importation  of  the  germ. 

European  outbreaks  have  happily  become  highly 
irregular  and  far  less  extensive.  At  the  present  time 
cholera  attacks  the  army  and  the  fleet,  and  it  also  makes 
its  appearance  on  board  ship.  Witness  the  epidemics 
on  board  the  steamers  Remo  and  Andrea  Doria,  sailing 
from  Genoa  to  South  America.  The  second  of  these 
caused  114  deaths  among  1357  emigrants. 

In  India  the  average  annual  death-rate  from  cholera 
between  1877  and  1886  was  298,000  ;  between  1901 
and  1910  it  was  380,000,  with  a  maximimi  of  710,000 
in  1906.  The  average  mortality  is  from  56  per  cent,  of 
those  attacked  (Madras)  to  77*8  per  cent.  (Bombay) 
(Pottevin). 

The  Dutch  East  Indies  are  not  free  from  the  disease 


HISTORICAL  409. 

Between  the  1st  January  and  the  26th  September 
1914,  1919  cases  and  1030  deaths  were  recorded. 

In  Germany  the  deaths  from  cholera,  which  were 
114,683  in  1866  and  27,790  in  1875,  fell  to  866  in  1892, 
83  in  1905,  and  14  in  1910. 

During  the  Balkan  War  the  third  Bulgarian  Army, 
held  in  check  before  the  trenches  of  Tchataldja,  suffered 
much  from  cholera.  By  the  18th  November  there  had 
been  17,000  cases  and  900  deaths ;  by  the  30th 
November  these  figures  had  risen  to  29,626  and  1849 
respectively.  The  number  of  cases  increased  more 
particularly  after  the  men  took  to  drinking  river  water 
in  which  the  corpses  of  Turkish  soldiers  were  drifting. 
The  civil  population  also  was  attacked. 

In  the  Turkish  Army,  during  the  same  period,  cholera 
appeared  all  the  more  readily  in  that  it  was  prevalent 
before  mobilisation  among  the  civil  population  of  Con- 
stantinople and  the  surrounding  district,  in  Syria,  etc. 

During  the  present  war  the  French  and  British  armies 
have  had  no  cases  of  cholera  up  to  date.  There  have 
been  very  severe  and  very  quickly -developing  cases  of 
acute  gastro-enteritis,  sometimes  fatal,  but  these  were 
found  to  be  due  to  paratyphoid  infections. 

On  the  other  hand,  the  Austrian  Army  and  civil 
population  have  been  very  severely  visited  by  cholera. 
Between  the  23rd  September  and  the  5th  December 
1914,  the  official  figures  for  Austria  were  3468  cases  and 
898  deaths.  In  Vienna,  during  the  same  period,  there 
were  386  cases  and  39  deaths. 

Carinthia,  Carniola,  and,  above  all,  Galicia  have  been 
the  scene  of  numerous  outbreaks.  During  September, 
October,  and  part  of  November,  1914,  Galicia  numbered 
3039  cases  and  1164  deaths.  In  Hungary,  during  the 
same  period,  there  were  3605  cases. 

A  few  cases  were  noted  in  Silesia  among  the  civil 
population  and  the  prisoners  (277  cases,  33  deaths) 
between  the  23rd  September  and  the  7th  November 
1914.  Bulgaria  and  Greece  were  also  invaded  by  the 
disease. 


410     DYSENTERY,  CHOLERA,  AND  TYPHUS 

In  Turkey  32  cases  and  17  deaths  were  reported  in 
Constantinople  during  the  early  months  of  1914  ;  at 
Adrianople  there  were  110  cases  and  94  deaths  among 
'the  troops  between  the  28th  February  and  the  19th 
May.  In  the  garrison  of  Rodosto  there  were  15  cases  ; 
in  that  of  Trebizond  14  cases  and  12  deaths  in  January, 
1914. 

We  see,  therefore,  that  the  importatioji  of  cholera 
into  belligerent  nations  which  it  has  hitherto  respected 
is  within  the  range  of  possibility. 


CHAPTER  XII 

ETIOLOGY    OF    CHOLERA.      FAVOURING 
FACTORS 

Caused  by  a  special  pathogenic  bacillus,  the  cholera 
vibrio,  cholera  is  nevertheless  not  unaffected  hy  favour- 
ing conditions,  some  of  which  are  individual,  while  others 
are  foreign,  or  extrinsic. 

The  comparative  protection  afforded  by  childhood  is 
explained  by  the  fact  that  children  at  the  breast  are 
usually  safe  from  alimentary  contagion. 

Nevertheless,  children  of  ten  months  may  contract 
the  disease,  while,  on  the  other  hand,  the  aged  are  by 
no  means  exempt  from  it. 

It  is  between  the  ages  of  twenty  and  thirty  years, 
and  above  all  in  the  male  sex,  that  cholera  is  most 
frequent. 

No  race  is  safe  from  its  attacks.  The  black  race 
appears  to  be  even  more  susceptible  than  others,  and 
the  mortality  from  cholera  is  very  much  higher  among 
them. 

No  doubt  certain  individual  cases  of  immunity  exist, 
but  they  are  rare.  The  effect  of  agglomerations,  wars, 
and  pilgrimages  has  been  invoked  ;  but  these  factors 
are  operative  only  because  they  multiply  human  con- 
tacts— ^that  is,  the  chances  of  contamination — and 
favour  the  transfer  of  the  bacillus. 

Alimentary  conditions,  such  as  the  employment  of 
raw  fruits  and  vegetables,  and  indigestible  foods,  have 
long  been  regarded  as  the  adjuvants  of  infection. 
Possibly  they  act  simply  and  solely  by  transport- 
ing the  bacillus.  But  alcoholism,  acute  or  chronic, 
seems  to  play  a  more  considerable  part,  for   it   in- 

411 


412    DYSENTERY,  CHOLERA,  AND  TYPHUS 

volves  an  insufficiency  of  the  digestive  and  hepatic 
secretions. 

At  the  time  of  the  Budapest  epidemic  of  1892-1895, 
22*4  per  cent,  of  those  attacked  were  alcohohcs ;  while 
during  the  Russian  epidemic  of  1908,  65  per  cent,  of 
those  struck  down  were  tainted  with  alcohoHsm.  This 
explains  why,  during  an  endemic  period,  we  often 
observe  the  greatest  number  of  patients  on  a  Monday. 

The  employment  even  of  pure  water  in  too  large 
quantities  may  lead  to  a  dilution  of  the  digestive  juices, 
and  thereby  favour  infection. 

Excessive  fatigue  has  often  been  incriminated,  not 
without  reason.  Its  evil  effects  have  often  enough 
been  exemplified  during  military  expeditions. 

Chronic  diseases,  tuberculosis,  and,  above  all,  in- 
flammation of  the  intestines,  appear  to  be  predisposing 
factors. 

Among  the  extrinsic  factors  hot  weather  and  the 
summer  are  most  frequently  incriminated. 

It  is  certainly  a  fact  that  the  majority  of  epidemics 
are  observed  during  this  season.  However,  epidemics 
are  on  record  which  attained  their  fastigium  in  the 
spring,  or  even  in  winter.  Such  was  the  Paris  epidemic 
of  1832  (which  occurred  in  winter),  that  of  Berghem 
(also  a  winter  epidemic),  and  the  Russian  epidemic  of 
1830,  when  the  disease  persisted  in  Moscow  during  a 
temperature  of  4°  F.  below  zero.  The  Lisbon  epi- 
demic broke  out  in  December,  1893,  and  the  Russian 
epidemic  of  1908  also  comrnenced  in  winter. 

Nevertheless,  heat  and  thundery  weather  favour 
cholera,  no  doubt  because  of  the  great  consumption  of 
waiter  which  they  involve. 

The  following  table,  borrowed  from  Bertillon,  indi- 
cates the  duration  and  the  season  of  various  epidemics, 
as  well  as  the  number  of  victims  claimed  from  the 
population  of  Paris. 

Cholera  becomes  localised  by  election  in  moist,  hot 
regions,  such  as  the  deltas  of  great  rivers  (the  Ganges, 
the  Nile).     In  such  regions  its  reign  is  prolonged,  while 


ETIOLOGY  OF  CHOLERA 


413 


in  high-lying  districts  and  elevated  tablelands  it  is  less 
persistent.  It  is  observed  principally  among  uncleanly 
populations,  in  towns  and  villages  where  hygiene  is  un- 
known, where  dejecta  are  left  lying  on  the  ground,  in 
native  quarters,  in  the  soks  and  suburbs,  while  the 
wealthy  quarters  are  frequently  spared.  The  epidemic 
of  Havre,  in  1892,  attacked  the  old  quarters  rather  than 
the  rest  of  the  town. 

In  1893  the  poverty-stricken  population  of  the  lies 
Mol^nes  and  Trielen  suffered  an  enormous  mortality. 


Year  of 

Date  of 

the  first 

Date  of 
the  last 

Duration  of 

Seasons 

during 

which  the 

Number 
of  Deaths 

Deaths  from 
Cholera  per 

Epidemic 

Death 
Recorded 

Death 
Recorded 

Epidemic  in 
months 

Epidemic 
was  most 
Violent 

attri- 
buted to 
Cholera 

100,000  jn- 
habitants  in 
each  Epidemic 

1832 . 

Mar.  26 

Sept.  30 

6  months 

/Spring   1 
\  Summer/ 

18,402 

2345 

1833 . 

Jan. 

Dec. 

12      „ 

Autumn 

505 

64 

1849 . 

Mar.  9 

Oct.  31 

8       „ 

Spring 

19,615 

861 

1854 . 

Jan.  1 

Dec.  29 

12      „ 

Summer 

8591 

732 

1865  . 

Sept.  1 

Dec.  31 

4      „ 

Autumn 

6357 

354 

1866  . 

July  1 

Oct.  31 

4       ,, 

Summer 

5218 

289 

1873 . 

Sept.  4 

Nov.  10 

2       ,, 

Autumn 

855 

46 

1884 . 

Nov.  3 

Dec.  31 

2      „ 

Autumn 

986 

44 

1892 . 

Aug. 

Dec. 

5       „ 

Summer 

713 

29 

In  the  hamlet  of  Trielen  there  were  fourteen  deaths  in 
six  days. 

The  Budapest  epidemic  of  1892-1893  manifested 
itself  almost  entirely  in  the  dirty  and  overcrowded 
houses  of  the  working  classes,  and  among  domestic 
servants  out  of  employment.  The  epidemic  of  Les 
Pouilles,  in  1910,  presented  the  same  peculiarity 
(Pottevin). 

There    are    certain    cases    of   individual    immunity, 
revealed    by   the    failure   to    absorb    cultures   of   the 
cholera  vibrio  (Metchnikoff),  and  owing  to  this   fact:; 
certain   subjects   may   escape   attack   although    their- 
dejecta  contain  vibrios. 


414     DYSENTERY,  CHOLERA,  AND  TYPHUS 

The  Determining  Causes  of  Cholera 

Cholera  results  from  the  toxi-infection  caused  by  the 
cholera  vibrio.  This  infection  is  localised  in  the  ali- 
mentary canal.  The  germ  is  most  commonly  absorbed 
by  way  of  the  mouth  and  the  digestive  organs.  Having 
entered  the  body  by  the  mouth,  in  one  of  the  ways  which 
will  be  explained  later  on,  the  bacillus  reaches  the 
stomach,  where  the  acid  secretion  is  prejudicial  to  it, 
but  various  circumstances,  such  as  the  ingestion  of  the 
microbe  when  fasting,  or  when  commencing  a  meal,  or 
the  absorption  of  a  large  quantity  of  contaminated  cold 
water,  which  flows  quickly  into  the  duodenum,  and 
thence  into  the  small  intestine,  may  protect  the  vibrio 
from  the  effects  of  the  acid  gastric  juice.  Having 
reached  the  small  intestine,  the  secretion  of  which  is 
alkaline,  and  which  contains  the  peptones  favourable 
to  its  culture,  it  there  multiplies  profusely,  provoking, 
at  this  point,  the  premonitory  diarrhoea. 

Such  is  the  first  stage  of  the  infection,  and  to  this 
stage  the  infection  may  be  confined.  More  com- 
monly the  bacilli  sow  themselves  on  the  surface  of 
the  epithelial  layer,  and  then  in  its  cellular  support,  and 
there  they  cause  first  desquamation  and  then  necrosis, 
owing  to  the  toxins  secreted.  In  the  dejecta,  frag- 
ments of  the  mucous  lining,  detached  and  dead,  are 
discovered. 

The  invasion  then  spreads  along  the  whole  extent  of 
the  small  intestine.  The  toxins  liberated  by  the 
bacilli,  and  those  which  result  from  the  death  or  dis- 
integration of  the  bacilli  destroyed,  are  absorbed  by  the 
large  absorbent  surface  offered  by  the  ill -protected 
or  desquamated  intestinal  lining.  Then  it  is  that 
the  characteristic  signs  of  the  choleraic  intoxication 
make  their  appearance,  the  most  important,  for  the 
epidemiologist,  being  the  diarrhoea  and  vomiting,  which 
are  usually  profuse. 

The  dejecta  and  the  vomit  contain  the  vibrio,  often 
in    prodigious    quantities.     They    are,    therefore,    the 


ETIOLOGY  OF  CHOLERA  415 

essential  intermediaries  of  contagion.  The  first  place, 
however,  must  be  awarded  to  the  alvine  evacuations. 

These,  indeed,  often  consist  of  ah  almost  pure  culture 
of  the  vibrio,  mingled  with  epithelial  fragments  which 
give  the  stools  their  rice-water  appearance,  the  bacilli 
swarming  in  them.  Through  the  breach  afforded  by 
the  sub-mucous  tissile,  deprived  of  its  epithelial  coating 
by  desquamation,  profuse  quantities  of  serous  liquid 
flow,  in  which  the  bacilli  vegetate.  The  multiplicity 
of  the  stools,  their  fluidity,  and  the  involuntary  emission 
of  evacuations  permit  of  the  easy  diffusion  of  these  pro- 
ducts, which  are  extremely  rich  in  bacilli.  Deposited 
everywhere,  on  underclothing,  body  linen,  sheets,  the 
soil,  etc.,  the  dejecta  carry  with  them'  the  patho- 
genic agent.  This  already  explains  the  excessive  con- 
tagiousness of  cholera. 

The  bacillus,  then,  .  is  transmitted  principally  by 
means  of  the  choleraic  stools:  these  are  the  chief 
source  of  infection.  We  shall  presently  see  that  cholera 
carriers  are  equally  contagious,  and  through  the  same 
medium. 

The  cholera  vibrio  also  exists  in  the  vomit  so  fre- 
quently emitted  during  the  development  of  a  case  of 
cholera,  but  it  is  much  less  abundant  there.  It  is  said 
to  have  been  found  in  the  sputum  (Mills), ^  but  not  in  the 
urine.  It  does  not  exist  in  the  blood,  intestine,  or 
spleen  of  the  foetus  taken  from  women  who  have  died 
of  cholera. 

The  elimination  of  bacilli  goes  on  during  the  whole 
course  of  the  disease,  and  sometimes  -even  long  after 
recovery. 

The  spread  of  the  vibrio  to  the  kinsfolk  of  the 
sufferer,  and  those  about  him,  is  therefore  effected  with 
the  greatest  facility.  For  this  reason;  especially  in 
former  years,  the  mortality  among  orderlies,  nurses,  and 
physicians  during  epidemics  has  been  enormous.  One 
single  sufferer  may  infect  numbers  of  persons ;  a  village, 
a  town,  a  continent  even.  On  the  5th  July  1854,  a  ship 
^  Greig's  work  loc.  cit.  supports  this. — Ed. 


416     DYSENTERY,  CHOLERA,  AND  TYPHUS 

having  landed  a  cholera  patient  at  the  Piraeus,  the 
epidemic  invaded  the  whole  of  Greece.  It  will  be 
understood  how  the  disease  may  be  transmitted  by 
caravans  and  shiploads  of  Mussulman  pilgrims  return- 
ing from  Mecca,  attacking,  on  their  return,  the  in- 
habitants of  the  countries  from  which  they  set  out. 

This  again  explains  how  the  great  epidemics  which 
ravaged  Europe  during  the  nineteenth  century  spread 
from  India  to  Russia  by  way  of  Persia,  Afghanistan, 
and  Arabia,  or  to  Egypt,  Turkey,  and  the  ports  of  the 
Mediterranean,  by  means  of  vessels  bringing  passengers 
from  the  East.  Cholera  is  transported  by  man,  and 
spreads  along  the  routes  followed  by  man.  Countries 
which  have  succeeded  in  isolating  themselves  entirely 
have  escaped  the  scourge. 

The  transmission  of  the  vibrio  is  effected,  not  only  by 
admitted  cholera  patients,  but  also  by  persons  suffering 
from  "  cholerine  "  or  summer  diarrhoea  (Kelsch).  All 
observers  have  noted  this  important  fact.  Moreover, 
the  experimental  absorption  of  cultures  may  give  rise 
to  these  slight  forms  of  diarrhoea  (Ferran,  Macrae,  etc.). 

These  cases  of  diarrhoea  due  to  a  vibrio,  mere  cases 
of  indisposition,  are  extremely  dangerous  in  respect  of 
contagion,  for  they  are  not  always  made  the  object  of 
special  precautions,  and,  on  the  other  hand,  they  are 
able  to  move -about  and  to  travel,  thereby  spreading 
the  microbe  wherever  they  go. 

It  has  frequently  been  observed  that  the  great  epi- 
demics have  been  preceded  by  an  unwonted  outbreak 
of  cases  of  diarrhoea  or  cholerine.  Such  was  the  case 
at  the  time  of  the  Russian  epidemic  of  1907-1908.  As 
early  as  June,  1908,  Jacovlev,  in  Petrograd,  noted  the 
increased  number  of  cases  of  intestinal  affections,  and 
of  the  deaths  due  to  them.  Moreover,  at  this  period 
the  bacillus  was  isolated  from  the  stools  of  a  patient 
who  had  recovered. 

To  sum  up :  the  vibrio  is  propagated  by  the  patients 
attacked  by  the  characteristic  forms  of  cholera ;  it  is  also 
propagated  by  those  who  are  suffering  from  abnormal  or 


ETIOLOGY  OF  CHOLERA  417 

prolonged  forms  of  the  same  disease  ;  further,  it  is 
transported  by  those  who  present  only  the  morbid 
symptoms,  slight  and  benign,  of  simple  diarrhoea,  bac- 
teriological examinations  nevertheless  enabling  the 
diagnostician  to  isolate  the  microbe. 

But  these  are  not  the  only  sources  of  contagion.  The 
vibrio  may  also  proceed  :  1.  From  patients  who  have 
recovered  more  or  less  recently  from  one  or  other  of  the 
clinical  forms  of  cholera  already  indicated. 

2.  From  perfectly  healthy  subjects,  who  have  been  in 
contact  with  cholera  patients,  or  have  absorbed  the 
vibrio,  but  who  nevertheless  have  presented  no  morbid 
symptoms. 

Both  types  constitute  what  are  known  as  "  carriers  " 
of  the  cholera  germ.  The  latter  play  a  very  important 
part  in  the  propagation  of  the  germ,  and  they  furnish 
the  explanation  of  the  apparent  spontaneity  of  certain 
epidemics  which  have  affected  families,  villages,  or 
towns.  We  ought,  therefore,  to  make  a  special  study 
of  these  carriers. 

The  Carriers  of  Cholera  Vibrios 

We  have  already  called  attention  to  a  special  category 
of  germ-carriers,  consisting  of  persons  suffering  from 
slight  or  insignificant  forms  of  diarrhoea.  In  practice 
we  must  not  form  any  conclusion  as  to  their  exist- 
ence until  we  have  made  cultures  from  their  dejecta. 
Jacovlev,  Zabolotny,  Zlatogorov,  and  Kulescha  have 
recorded  the  presence  of  the  vibrio  in  subjects  who 
were  merely  passing  liquid  stools.  In  July,  1909, 
several  very  grave  cases  of  cholera  having  appeared 
in  the  General  Hospital  in  Calcutta,  it  was  discovered 
that  these  cases  were  due  to  two  natives,  who,  having 
the  appearance  of  normal  health,  but  suffering  from 
slight  attacks  of  gastro-enteritis,  were  carriers  of  the 
bacillus. 

In  patients  who  have  recovered  from  cholera  the 
vibrio  persists  in  36  per  cent,  while  the  period  during 


418     DYSENTERY,  CHOLERA,  AND  TYPHUS 

which  it  may  be  found  varies  from  two  days  to  two 
months,  and  sometimes  more  (Michailov,  Komme- 
laere,  Zlatogorov).  The  confirmation  of  this  possible 
persistence  of  the  vibrio  in  the  stools — though  these  may 
be  normal — of  ex-cholera  patients  was  established  by 
Forrest,  in  India,  by  Marcovich,  in  the  Trentino  (1910), 
by  Franca,  in  Madeira  (1910),  and  by  Defressine  and 
Cazeneuve,  in  Marseilles  (1912).  Somewhat  exception- 
ally the  persistence  of  the  microbe  may  exceed  a  period 
of  2  months.  It  may  persist  for  69  days  (in  the  epi- 
demic of  Petrograd,  1908-1909),  90  days  (Zeidler),  or 
100  days  (Marcovich). 

The  labours  of  Russian  and  Italian  physicians  have 
done  much  to  throw  light  upon  this  important  point. 
Montefusca,  examining  the  stools  of  107  convalescents, 
found  the  vibrio  persisting  in  60  of  these  subjects  for 
15  days  ;  in  40  it  persisted  for  a  period  varying  from 
15  to  30  days  ;  in  2  it  persisted  for  35  days,  and  in  the 
rest  from  38  to  78  days.  Vanda  isolated  the  bacillus 
for  more  than  10  days  from  30  per  cent,  of  his  con- 
valescents ;  for  10  to  20  days  from  10  per  cent.  ;  and 
for  36  to  56  days  from  8  per  cent.  In  the  case  of  24 
convalescents  who  appeared  to  be  rid  of  the  bacillus  a 
slight  purgative  caused  its  reappearance  in  3  of  the  24. 
The  administration  of  a  purgative  (15  grammes  of 
magnesium  sulphate),  recommended  by  Zirolia,  some- 
times enables  the  physician  to  discover  that  the  dis- 
appearance of  the  germ  is  only  apparent .  On  the  other 
hand,  an  attack  of  indigestion  or  an  alimentary  excess 
may  produce  the  same  result. 

Other  investigations  made  in  Italy  on  over  3000 
healthy  carriers  of  the  bacillus  showed  that  50  per  cent, 
of  the  carriers  no  longer  carried  the  vibrio  after  five 
days  ;  77  per  cent,  of  the  other  carriers  revealed  the 
germ  on  the  tenth  day ;  and  95  per  cent,  on  the  twentieth 
day  (Pottevin). 

Baldoni  examined,  at  Brescia,  between  the  5th  of 
August  and  the  month  of  December,  1915,  5200  faeces 
passed  by  soldiers  under  treatment  or  in  quarantine. 


ETIOLOGY  OF  CHOLERA  419 

He    found   that    2-5    per    cent,    of    the   latter    were 
carriers. 

There  is  no  longer  any  doubt  that  certain  persons  are 
capable  of  retaining  the  vibrio  for  considerable  periods. 
The  designation  of  "  chronic  carriers,"  although  it 
represents  a  rare  eventuality,  denotes  the  existence  of 
these  cases.  Cases  of  long-continuing  diarrhoea  have 
been  noted  in  which  the  microbe  has  persisted  for  a 
period  of  six  months  (Alain,  Vallee  and  Martineau, 
Ruffer),  a  year,  and  even  three  years  (Crendiropoulo  and 
Panayotatau). 

Analysing  the  researches  conducted  by  the  preceding 
writers,  and  also  by  Piras,  Debonis,  Defressine  and 
Cazeneuve,  Necchi  and  Randone,  etc.,  it  follows  :  (1) 
that  the  cholera  vibrio  may  persist  after  the  complete 
recovery  of  the  patient  in  about  30  to  33  per  cent,  of 
cases  ;  (2)  that  this  persistence  is  not,  as  a  rule,  very 
prolonged,  but  continues  at  most  for  thirty  or  forty 
days,  rarely  more  ;  (3)  that  the  excretion  of  the  vibrio 
may  be  irregular,  intermittent  and  interrupted  for  a 
few  days,  and  then  reappears. 

From  this  last  point  of  view  the  facts  are  analogous 
to  those  which  have  been  established  in  respect  of 
carriers  of  the  bacillus  of  typhoid,  but  the  long  persist- 
ence of  the  latter  bacillus,  which  may  continue  during  a 
lifetime,  does  not  obtain  in  the  case  of  the  carrier  of 
the  cholera  vibrio. 

In  practice  it  is  always  useful,  before  concluding  that 
the  vibrio  has  disappeared,  to  make  repeated  cultiva- 
tions and  previously,  on  each  occasion,  to  administer 
a  gentle  saline  purgative. 

The  existence  of  healthy  carriers — that  is,  carriers  who 
have  never  suffered  from  cholera,  even  in  an  obscure  or 
attenuated  form — is  to-day  fully  demonstrated.  The 
truth  is  that  there  are  carriers  whose  blood  contains 
antibodies,  which  shows  that  the  choleraic  infection 
must  have  been  serious.  Klein,  who  frequently  isolated 
them,  owing  to  this  observation,  queried  the  specific 
and  pathogenic  character  of  the  vibrio  described  by 


420     DYSENTERY,  CHOLERA,  AND  TYPHU8 

Koch.  Persons  who,  in  time  of  cholera,  absorb  the 
vibrio  but  escape  infection,  possess,  in  reaUty,  only  a 
relative  immunity.  Their  existence  has  been  verified 
by  many  writers  during  epidemics,  and  in  various 
countries.  In  Russia  Jacovlev  found  that  in  100 
instances  of  isolation,  the  bacillus  was  in  twenty  cases 
derived  from  healthy  subjects.  At  the  time  of  the 
Russian  epidemic,  during  the  three  months  commencing 
on  the  21st  December  1908,  the  stools  of  2440  persons 
who  had  been  in  contact  with  cholera  patients  were 
examined.  The  vibrio  was  isolated  125  times,  or  in 
5  per  cent,  of  these  cases. 

These  carriers  fell  into  three  groups  : 

1.  Twenty-five  were  in  the  incubation  stage  of 
cholera.i 

2.  Forty  were  emitting  rather  liquid  stools,  without 
morbid  symptoms. 

3.  Sixty  exhibited  normal  stools,  and  presented  no 
sign  of  disease. 

According  to  more  extensive  data  published  by 
Jacovlev,  Zlatogorov,  and  Kulescha,  the  examination 
of  21,962  persons  yielded  the  cholera  vibrio  4497  times. 
Of  9752  persons  who  had  been  in  contact  with  cholera 
patients  571  were  carriers  of  the  bacillus. 

The  proportion  of  these  healthy  carriers  among  those 
who  form  the  entourage  of  cholera  patients  may  vary, 
however,  within  wide  limits.  The  average  proportion 
is  6  to  7  per  cent.  (MacLaughlin,  Forrest).  Such  carriers 
have  been  found  among  pilgrims  on  their  return  from 
Mecca  (Zonchello).  They  were  also  found  on  the 
occasion  of  the  epidemic  which  visited  Holland  in  1909  ; 
in  the  Belgian  epidemic  (Van  der  Velde),  the  Marseilles 
epidemic  of  1912  (Salimbeni  and  Dopter,  Orticoni), 
the  Italian  epidemic  (Vivaldi),  and  the  epidemics  in 
Madeira  (Franca  and  Stevens),  and  Tunis  (Conor).     The 

^  Cholera  made  its  appearance  one  to  three  days  later.  We  have 
here  the  confirmation  of  the  idea  that  the  cholera  subject  may  be  con- 
tagious before  the  appearance  of  the  first  symptoms  of  cholera  (Edm; 
Sergent,  L.  Negre,  Bregeat  and  Vivien). 


ETIOLOGY  OF  CHOLERA  421 

proportion  of  carriers  may  be  very  high — as  high  as  14 
per  cent,  (as  in  the  Genoa  epidemic  of  1911,  when  of 
1525  persons  214  were  found  to  be  carriers).  On  the 
other  hand  it  may  be  very  low,  or  the  carriers  may  be 
non-existent.  Crendiropoulo,  examining  the  stools  of 
34,461  persons  in  Egypt,  isolated  the  vibrio  from  only 
25  of  them.  At  the  time  of  the  Madeira  epidemic  not 
one  of  the  seventy-one  physicians  or  nurses  was  found 
to  be  a  carrier.  It  results  from  this  that  a  thorough 
prophylaxis  may  prove  to  be  a  perfect  protection  against 
infection  by  the  vibrio,  whether  latent  or  effective. 

It  has  been  queried  whether  the  vibrios  thus  isolated 
from  the  dejecta  of  healthy  carriers  have  pathogenic 
properties.  Attempts  to  inoculate  animals  have  some- 
times proved  their  low  degree  of  virulence  (Piras), 
and  sometimes  their  activity  and  toxicity  (Debonis, 
Cimmino,  etc.). 

The  period  during  which  the  germ-carrier  eliminates 
the  cholera  vibrio  is  fairly  brief,  varying  from  a  few 
days  to  three  weeks. 

Between  the  4th  of  December  1908  and  the  4th  of 
December  1909  the  Service  of  Hygiene  in  Petrograd  ex- 
amined the  faeces  of  9357  subjects  who  had  been  isolated 
as  possibly  contaminated.  Of  these  577  were  carriers 
of  the  vibrio.  Between  the  4th  of  December  1909  and 
the  4th  of  December  1910,  3173  persons  exposed  to 
contagion  through  their  proximity  to  cholera  patients 
were  examined  in  the  same  way.     The  results  were  : 

Adults        .         .         .     2368     .         .     157  carriers  =   6 '6  per  cent. 
Children,  1  to  15  years     720    '.         .71        ,,        =   9"8         ,, 
Children  under  1  year         85     .         .       17       ,,       =20  ,, 

(Pottevin).  Children,  accordingly,  are  particularly 
dangerous. 

In  connection  with  the  cholera  in  Hedjaz,  it  has  been 
noted  that  the  pilgrims,  who  yield  so  many  cases  of  the 
disease,  also  exhibit  instances  of  healthy  carriers.  In 
1912-1913,  2-8  per  cent,  of  the  pilgrims  had  agglutinable 
vibrios  in  their  stools. 


422      DYSENTERY,  CHOLERA,  AND  TYPHUS 

It  was  in  the  Egyptian  hospitals  that  the  discovery 
of  suspected  vibrios  was  first  made  wi£h  any  frequency. 
In  certg^in  cases  of  ulcerative  gangrene  of  the  intestine 
a  vibrio  identical  with  that  of  cholera  was  isolated. 
In  90  post-mortem  examinations  suspected  vibrios 
were  discovered  in  36  instances :  some  of  these  being 
extremely  virulent,  agglutinable,  secreting  a  haemolysin, 
etc. 

In  subjects  returning  from  Mecca  and  dying  of  various 
diseases  (such  as  dysentery),  cultures  have  yielded  a 
vibrio  (the  vibrio  of  El  Tor)  analogous  to  the  cholera 
vibrio,  agglutinable  by  anti-choleraic  serum,  and 
showing  Pfeiffer's  reaction.  Nevertheless,  it  seems  that 
we  ought  to  regard  these  bacilli  as  paracholera  vibrios. 
Castellani  has  isolated  paracholera  bacilli  in  Ceylon. 

The  important  part  played  by  the  carriers  of  bacilli 
in  the  extension  of  epidemics  of  cholera  need  not  be 
emphasised.  The  perennial  nature  of  the  disease  in 
certain  countries,  its  persistence,  and  its  periodical  or 
irregular  return  in  others,  can  oiUy  be  explained  by  the 
persistence  of  the  germ  in  certain  persons  who  act  as 
reservoirs  or  depositories.  A  healthy  subject,  travelling 
through  a  given  country,  or  sojourning  in  it  awhile, 
may  thus  become  the  origin  of  serious  epidemics. 

The  conditions  which  thus  permit  of  the  conservation 
and  retention  of  the  cholera  vibrio,  during  a  variable 
period,  by  a  certain  mimber  of  persons  who  have  or  have 
not  suffered  from  an  attack  of  cholera,  are  the  same  as 
those  which  obtain  in  the  case  of  carriers  of  the  bacillus 
of  typhoid,  or  the  paratyphoid  bacilli.  The  cultivation 
of  the  contents  of  the  gall-bladder  on  the  occasion  of 
autopsies  on  victims  of  cholera  first  enabled  Nicati  and 
Rietsch,  during  the  Marseilles  epidemic  of  1884,  to  isolate 
the  comma  bacillus.  This  important  discovery  was  veri- 
fied by  Tizzoni  and  Cattani,  and  by  Doyen,  Raptchevski, 
Sevastianov,  Rekovsky,  Tanda,  etc.  The  vibrio  is  not, 
as  a  matter  of  fact,  absolutely  constant  in  the  gall- 
bladder ;   but   its  occurrence  there  is  frequent,  since 


ETIOLOGY  OF  CHOLERA  423 

Brullov  found  it  in  76  per  cent,  of  cases,  and  Otto  SchSbl, 
in  the  Philippines,  in  18  cases  out  of  39. 

Kulescha  concluded,  after  conducting  430  autopsies, 
that  the  vibrio  is  most  frequently  encountered,  first  in 
the  intestine,  and  then  in  the  gall-bladder.  As  in 
typhoid  infection,  the  local  multiplication  of  the  vibrio 
determines  catarrhal  and  haemorrhagic  lesions  of  the 
mucous  membrane  of  the  gall-bladder,  sometimes 
amounting  to  a  true  cholecystitis.  The  same  microbe 
may  give  rise  to  suppurative  angiocholitis,  with  jaundice 
(Piras).  During  the  epidemic  of  Toulon  (1911)  Defres- 
sine  and  Cazeneuve  found  the  vibrio  in  the  pure  state 
in  the  bile  of  three  patients  who  had  succumbed  to 
cholera,  the  cultivations  having  been  made  four  to  eight 
hours  after  death. 

As  regards  the  bacteriological  diagnosis  post  mortem, 
therefore,  the  search  for  the  vibrio  in  the  bile  may  be 
of  great  service  ;  but  it  should  be  undertaken  in  good 
time. 

Experimentally,  Baroni  and  Ceaparu  have  discovered 
the  existence  of  the  vibrio  in  the  bile  of  inoculated 
rabbits.  Job  has  observed  that  if  the  guinea-pig  is 
made  to  absorb  the  vibrio  it  may  be  found  in  the  blood, 
in  which  it  remains  for  a  short  time,  and  then  in  the 
gall-bladder.  He  believes  that  the  intestinal  phase  of 
cholera  is  preceded  by  a  septicsemic  phase. 

Otto  Schobl  has  "observed  the  brief  survival  of  the 
vibrio  in  guinea-pigs  inoculated  in  the  gall-bladder,, 
the  stomach,  or  the  intestine.  Intravenous  injection 
is  more  favoiu'able. 

However  this  may  be,  the  passage  of  the  bile  into  the 
intestine  explains  the  presence  of  the  vibrio  in  the 
dejecta  of  carriers. 

It  is,  therefore,  through  the  medium  of  their  excreta  thai 
the  carriers  of  vibrios,  like  those  suffering  from  cholera, 
disseminate  the  bacillus  and  become  contagious.  The 
contagiousness  of  the  carrier  is  inferior  to  that  of  the 
actual  cholera  patient,  because  the  number  of  bacilli 
eliminated  by  the  former  is  very  much  smaller. 


CHAPTER  XIII 

ETIOLOGY    OF    CHOLERA— con^mue^^ 
The  Modes  of  Propagation  of  the  Cholera  Vibrio 

Issuing  from  the  cholera  patient,  or  from  a  carrier  of  the 
bacilli,  the  cholera  vibrios  contained  in  the  dejecta  pro- 
ceed to  contaminate  linen,  chamber  utensils,  latrines, 
privies,  the  soil,  water,  etc.  They  may  be  transferred 
by  the  sufferer  or  the  carrier  to  those  who  attend  on  him 
or  surround  him ;  the  contagion  is  in  that  case  direct. 
They  may  on  the  other  hand  be  propagated  by  one 
of  the  intermediate  agencies  mentioned  below  :  the 
contagion  is  then  indirect. 

Innumerable  examples  testify  to  the  propagation  of 
the  cholera  bacillus  from  man  to  man.  Examples  of 
the  direct  propagation  of  the  vibrio  by  germ-carriers 
have  also  been  published.  In  families  and  collections 
of  people,  persons  whose  duty  it  is  to  prepare  food  (cooks, 
etc.),  when  they  are  germ-carriers,  are  particularly 
dangerous.  At  the  time  of  the  Petrograd  epidemic  a 
female  cook  in  a  house  of  retreat  who  had  prepared  a 
dish  with  gelatine  contaftiinated  forty- seven  persons 
thereby.  Kulescha  has  recorded  the  case  of  an  old 
lady  who,  having  a  terrible  dread  of  cholera,used  to  have 
her  crockery  boiled,  and  her  food  sterilised,  while  she 
frequently  disinfected  her  hands  and  employed  only 
boiled  water  for  her  bath.  None  the  less  she  contracted 
cholera,  of  which  she  died.  Inquiry  proved  that  she 
had  been  contaminated  by  her  l)aci]li-carrying  cook,  who 
lived  in  a  neighbouring  house,  and  had  been  in  contact 
with  cholera  patients. 

W.  Greig  records  that  an  epidemic  which  broke 
out  in  the  prison  at  Puri,  in  India  (1912),  was  due  to 

424 


ETIOLOGY  OF  CHOLERA  425 

the  communication  of  the  infection  by  a  vagrant  who 
had  previously  suffered  from  cholera.  Imprisoned  on 
the  25th  July,  a  few  days  later  he  had  caused  seven- 
teen cases  among  the  rest  of  the  prisoners  and  the 
warders.  There  were  five  deaths.  His  dejecta  con- 
tained numerous  vibrios. 

There  is,  therefore,  a  useful  comparison  to  be  drawn 
between  the  modes  in  which  cholera  is  transmitted  and 
those  by  which  typhoid  fever  and  the  paratyphoid 
fevers  are  transmitted.  Cases  of  infection  by  contact 
are  in  reality  cases  of  infection  by  means  of  dirty  hands, 
the  hands  of  the  person  who  transmits  the  germ  and 
contaminates  other  persons,  or  the  hands  of  the  person 
who  is  infected,  and  contaminates  himself,  by  neglect- 
ing to  wash  his  hands. 

It  is  easily  understood  that  direct  contagion  readily 
occurs  in  working-class  circles,  in  country  districts,  and 
among  the  natives  of  non-European  countries,  because 
the  general  conditions  of  hygiene  and  cleanliness  are 
less  regarded  there. 

The  original  centre  of  contagion  being  in  faecal  matter, 
we  may  well  ask  ourselves  what  becomes  of  the  vibrio, 
and  how  long  it  can  survive — that  is,  remain  con- 
tagious. We  know  that  according  to  R.  Koch  and 
certain  others  the  vibrio  is  supposed  not  to  persist 
longer  than  twenty-four  hours  in  the  dejecta,  But 
investigations  made  by  Mattei  and  Canalis  have  shown 
that  in  putrefying,  and  therefore  alkaline  dejecta,  the 
bacillus  may  survive  for  two  or  three  months.  Filov 
found  that  it  persisted  from  18  to  101  days ;  Rabescha, 
for  9  months.  It  is  in  fsecal  matter,  sheltered  from  the 
air  and  the  light,  that  the  vibrio  persists  longest  (Zlato- 
gorov).  Job,  having  during  the  winter  mingled  cholera 
vibrios  with  faecal  matter,  made  cultivations  every 
three  days  in  peptonised  water,  peptonised  and  saline 
agar,  etc.  He  found  that  the  bacilli  persisted  for  4  to 
33  days. 

Investigations  as  to  the  persistence  of  the  vibrio  in 
various  media  give  the  following  data  :— In  moist  sand, 


426    DYSENTERY,  CHOLERA,  AND  TYPHUS 

7  days ;  in  moist  garden  soil,  33  to  68  days  ;  in 
moistened  dust,  4  months.  Investigations  as  to  its 
persistence  on  the  surface  of  a  great  variety  of  food- 
stuffs give  the  following  results  : — On  barley  bread, 
1  to  3  days  ;  on  ordinary  bread,  covered  up,  7  days  ; 
on  smoked  herring,  4  days  ;  on  meat,  8  days  ;  on  fruits 
and  salad,  2  days  ;  on  fresh  apples,  cut,  4  days,  etc. 
In  reality  the  nature  of  the  substratum  matters  less 
than  the  conditions  of  dryness  or  humidity,  the  action 
of  light  and  of  the  oxygen  of  the  air,  and  the  degree 
of  acidity  of  the  medium,  which  affects  the  vitality 
of  the  bacilli.  During  the  sojourn  of  varying  length 
which  the  vibrio  makes  in  the  outer  world  while 
incorporated  in  faecal  matter,  it  is,  as  a  rule,  imperfectly 
protected.  In  reality  it  offers  little  resistance;  desic- 
cation kills  it  in  3  or  4  days,  or  at  most  in  13  to  38  days 
(Kitasato).     Antiseptics  and  acids  kill  it  quickly. 

One  may  conclude,  in  consequence  (1),  that  apart 
from  immediate  or  direct  transmission,  the  cholera 
vibrio  is  transmitted  by  means  of  indirect  or  inter- 
mediate factors  of  transmission :  hy  all  the  extremely 
various  intermediaries  on  which  the  alvine  evacuations  of 
cholera  patients  or  the  dejecta  of  carriers  may  be  deposited. 

2.  That  its  conservation  will  be  the  more  readily  effected 
as  the  receptive  medium  is  more  humid,  and  better  pro- 
tected from  the  microbicidal  action  of  light  and  the 
oxygen  of  the  air. 

3.  That  as  desiccation  has  the  effect  of  killing  the 
bacillus,  its  propagation  by  means  of  dust  is  hardly 
probable,  and  would  at  best  be  greatly  restricted. 

4.  That  contaminated  articles  of  food,  especially  liquid 
food,  are  contagious  factors  of  the  first  order. 

The  intermediate  agents  which  may  serve  to  propa- 
gate the  cholera  vibrio  are  either  living  and  animated, 
or  inert.  Both  play  a  more  important  part  than  that  of 
direct  contagion  in  all  localities  subjected  to  a  thorough 
personal  hygiene.  This  is  why  it  was  said  that  direct 
infection,  or  infection  by  contact,  "  played  only  an 
insignificant    part    in    the    hospitals    of    Petrograd," 


ETIOLOGY  OF  CHOLERA  427 

althougli  in  these  hospitals  the  cholera  patients  were 
very  insufficiently  divided  from  the  other  patients. 
We  must  therefore  award  an  important  place  to  in- 
direct contagion. 

This  is  commonly  effected  by  means  oi  flies.  During 
the  hot  season,  at  the  period  of  their  chief  activity,  the 
part  played  by  flies  is  a  considerable  one.  The  vibrio 
lives  in  the  alimentary  canal  of  the  fly.  Maddox  has 
verified  its  presence  in  Calliphora  vomitoria  and  Eris- 
talis  tenax.  Savtchenko,  having  fed  flies  upon  cultures 
of  the  cholera  vibrio,  found  the  vibrio  in  a  pure  culture 
in  their  intestines.  Ganon,  similarly,  verified  its 
presence  20  hours  after  an  infectious  meal.  Accord- 
ing to  Passek,  the  vibrio  lives  72  hours  in  the  fly's 
intestine. 

Tizzoni  and  Cattani  have  isolated  the  bacillus  from 
flies  captured  in  the  rooms  of  cholera  patients.  Tiskov 
and  Tsukuki  have  done  the  same. 

Flies  alight  upon  the  vomit  or  excrement  of  cholera 
patients,  thus  loading  themselves  with  vibrios,  which 
they  absorb,  or  with  which  they  soil  their  feet  and  legs. 
They  defsecate  very  frequently,  depositing  the  specific 
infection  upon  all  sorts  of  articles  of  food — fruits,  sweets, 
cakes,  custard,  pork,  bacon,  etc.  Lastly,  they  pollute 
the  face  and  hands  of  sleeping  children  and  adults. 
The  bacillus  survives  for  several  days  on  the  surface  of 
most  articles  of  food. 

The  vibrio  does  not  live  long  on  cut  fruits  whose  jiiice 
is  acid.  It  survives  longer  on  very  ripe  fruits,  on  the 
melon,  the  grape  (3  to  4  days),  and  the  date.  Putrefac- 
tion and  mould,  etc.,  have  little  effect  upon  its  vitality. 

Often  enough  the  flies  die  within  a  few  days;  their 
dead  bodies  then  may  fall  upon  food  and  pollute  it. 
This  is  why  the  proximity  of  kitchens,  dining-rooms, 
mess-rooms,  tents,  larders,  slaughter-houses,  pork 
butcheries,  butchers'  shops,  pastry-cooks'  shops,  etc., 
to  privies,  stables,  accumulations  of  dung  or  organic 
refuse,  or  to  hospitals,  may  in  seasons  of  epidemic  entail 
the  most  serious  danger. 


428    DYSENTERY,  CHOLERA,  AND  TYPHUS 

Flies,  moreover,  may  cover  long  distances,  being 
transported  by  carts,  carriages,  railways,  and  ships. 

The  pollution  of  food  may  be  effected  not  only  by 
flies,  but,  as  has  been  said,  by  cholera  patients  and  by 
germ-carriers,  by  the  soil,  and  by  water  (as  in  the  case  of 
raw  fruits  and  vegetables). 

Cases  of  contagion  have  been  reported  which  were 
due  to  polluted  clothing,  especially  to  linen  (shirts, 
sheets,  etc.).  The  calling  of  washerwoman  in  a  special 
manner  exposes  those  who  follow  it  to  infection  by 
cholera  vibrios.  Duflocq  has  published  examples  of 
these  various  modes  of  contagion.  The  cholera  bacillus 
multiplies  on  the  surface  of  a  piece  of  soiled  linen  which 
has  been  folded  up.  Its  period  of  vitality  is  from 
eight  to  twelve  days  on  damp  stuffs,  and  one  to  four 
days  on  dry  fabrics.  On  damp  cloth,  protected  from 
the  air  and  the  light,  it  may  survive  for  five  weeks 
(Gamaleia). 

Contagion  by  means  of  footgear  may  be  compared 
with  the  foregoing  means  of  contagion.  It  occurs  on 
soil  which  has  had  dejecta  thrown  upon  it,  or  in  gardens, 
or  ill-kept  privies,  etc.  The  germ  is  thus  introduced 
into  the  dwelling-house  by  the  boots  or  shoes,  or  by 
wooden  shoes  or  clogs,  or  by  bare  feet  even  in  country 
districts.  It  thus  becomes  deposited  on  the  hands,  or 
on  the  floor,  whence  it  is  picked  up  by  flies,  or  by 
children  at  play.  This  is  one  of  the  ways  in  which  the 
cholera  microbe  may  be  introduced  into  the  organism. 
It  must,  of  course,  reach  the  mouth.  This  it  may  do 
in  a  great  variety  of  ways. 

The  infection  of  the  soil  may  also  be  effected  by 
means  of  the  bodies  of  the  victims  of  cholera,  which 
carry  with  them  a  stupendous  quantity  of  pathogenic 
germs.  In  them  the  bacillus  may  survive  for  twenty- 
eight  days.  In  India  the  religious  practice  of  the 
natives,  who  place  the  corpses  of  those  who  have  died 
of  cholera  on  the  banks  of  the  Ganges,  favours  the 
infection  of  the  water  of  the  river. 

The  same  microbe  which,  mixed  with  the  dejecta  of 


ETIOLOGY  OF  CHOLERA  429 

cholera  patients  or  germ-carriers,  pollutes  the  surface 
of  the  soil  may  also  contaminate  vegetables  and  fruits 
which  have  fallen  from  the  trees.  According  to  Rem- 
linger  and  Nouri,  fish  living  in  contaminated  water  may 
preserve  the  vibrio  intact.  It  may  survive  within  the 
fish  for  two  to  four  days  (Gran  and  Shor). 

Infection  by  water  holds  the  first  place  in  the  pro- 
pagation of  cholera,  as  in  that  of  typhoid  fever. 

The  cholera  vibrio  retains  its  vitality  in  water  for 
considerable  periods  (Nicati  and  Rietsch,  Straus  and 
Dubarry).  Investigations  undertaken  to  elucidate  this 
point  have  yielded  results  which  are  not  absolutely 
concordant.  According  to  some  the  microbe  may  live 
for  thirty  to  eighty  days  in  well  or  river  water,  while, 
according  to  others,  it  can  only  live  for  seven  days  (Santi 
Sirena,  Dunham,  etc.).  It  is  possible  that  the  cholera 
vibrio  not  only  survives,  but  even  undergoes  multipli- 
cation in  still  waters,  when  it  is  sheltered  from  the 
light  and  when  the  external  temperature  is  sufficiently 
high. 

Hankin,  however,  has  called  attention  to  the  fact 
that  the  waters  of  the  Ganges,  and  of  its  affluent,  the 
Jumna,  possess  bactericidal  properties  in  respect  of  the 
cholera  bacillus.  Filtered  water  in  which  vibrios  had 
been  placed,  and  which  was  subjected  to  bacteriological 
examination,  yielded,  at  the  outset,  7000  to  8000 
colonies,  but  was  sterile  at  the  end  of  three  hours.  This 
property  disappeared  on  boiling.  To  tell  the  truth,  it 
appears  to  be  exceptional. 

The  effect  of  solar  light  on  water,  even  when  diffuse, 
has  a  powerful  bactericidal  effect.  Clear  water,  holding 
the  cholera  vibrio  in  suspension,  and  exposed  to  the 
rays  of  the  sun,  is  sterilised  in  three  to  four  hours.  In 
hot  countries  those  waters  which  are  sheltered  from  the 
solar  rays,  such  as  the  water  of  ponds,  and  of  the  Indian 
tanks,  are  particularly  dangerous.  The  renewed  con- 
tamination of  water  by  the  introduction  of  dejecta,  the 
washing  of  the  underclothes  of  cholera  patients  or 
germ-carriers,  the  discharge  of  contaminated  brooks 


430    DYSENTERY,  CHOLERA,  AND  TYPHUS 

or  tributaries  into  a  river,  form  many  causes  of  the 
persistence  of  the  infectious  germ. 

The  causes  of  the  contamination  of  water-suppUes  by 
the  bacillus  of  cholera  are  indeed  extremely  numerous. 
The  rains  favour  the  direct  discharge  of  dejecta,  of 
putrid  liquids,  of  contaminated  manure-pits,  into 
rivers  or  bodies  of  standing  water.  The  subsoil  layer 
is  exposed  to  the  same  infection,  through  the  infiltra- 
tions which  reach  it,  and  which  originate  either  on  the 
surface  (owing  to  the  spreading  of*  faecal  matter  on  the 
soil)  or  at  a  deeper  level  (from  cesspits). 

The  bacilli  constantly  swept  down,  in  times  of  epi- 
demic, by  rain-water,  sewage,  the  washing  of  linen,  etc., 
maintain  the  noxious  condition  of  water-supplies.  In 
the  Ganges  the  water  of  the  river  itself  does  not  im- 
mediately kill  the  bacillus.  The  religious  practices  of 
the  Hindus,  which  prescribe  baths  and  ablutions  in 
the  sacred  river,  and  the  ingestion  of  the  water  into 
which  corpses  are  thrown,  are  in  the  highest  degree 
favourable  to  infection. 

The  direct  proof  of  the  presence  of  the  cholera 
bacillus  in  a  large  number  of  suspected  rivers  was 
obtained  long  ago.  Nicati  and  Rietsch  isolated  it  on 
several  occasions  from  the  waters  of  the  Old  Port  of 
Marseilles.  Sanarelli,  Metchnikoff,  Netter,  Vincent, 
etc.,  have  also  verified  its  presence  in  different  waters. 
At  the  time  of  the  epidemic  which  prevailed  in  Petro- 
grad  in  1908,  1010  samples  of  the  water  of  the  Neva 
yielded  the  vibrio  193  times.  In  the  same  water  when 
filtered,  which  serves  as  drinking-water,  the  bacillus 
was  found  in  13  per  cent,  of  the  specimens  analysed; 
and  in  6-1  per  cent,  of  the  specimens  of  ice  examined. 
The  investigations  undertaken  by  Zabolotny  and  his 
colleagues  resulted  in  the  isolation  of  the  vibrio  from 
549  of  3505  samples  of  water. 

Huylov  isolated  the  vibrio  from  the  water  of  the 
Volga.  In  this  water  the  vibrio  persists  for  508  days, 
a  fact  which  can  only  be  explained  by  its  actual  multi- 
plication.    River-mud  is  a  receptacle  favourable  for 


ETIOLOGY  OF  CHOLERA  431 

the  preservation  of  the  microbe,  and  the  stirring  up  of 
the  mud  has  been  incriminated  as  the  cause  of  the 
contamination  of  river- waters. 

The  muddy  bottoms  of  wells  are  said  to  possess 
the  same  property.  Defressine  and  Cazeneuve  have 
isolated  the  vibrio  from  the  mud  of  a  river. 

.Similar  discoveries  have  been  made  in  all  countries, 
notably  in  Italy.  One  must  suppose  that  the  specific 
contamination  of  water,  and  especially  of  river-water, 
is  maintained  by  the  dejecta  of  the  carriers  of  germs. 

Epidemiology,  as  a  matter  of  fact,  confirms  at  every 
point  the  etiological  role  of  drinking-water  in  the  pro- 
pagation of  cholera.  This  role  is  an  important  one. 
At  the  time  of  the  epidemic  which  prevailed  in  France 
in  1884,  Marey,  in  his  well-known  report  to  the  Academy 
of  Medicine,  demonstrated  with  remarkable  precision 
the  influence  of  this  factor,  describing  epidemics  in 
certain  districts  or  villages  which  were  attributable  to 
the  absorption  of  contaminated  water,  the  disease 
spreading  through  the  different  villages  strung  out 
along  the  same  water-course.  A  sufferer  brought  the 
germ  to  the  hamlet  of  Val,  in  the  canton  of  Vignolles. 
His  linen  was  washed  in  a  wash-house  from  which 
the  water  drained  into  a  little  river  flowing  on  to 
Montfort.  At  Montfort  there  was  a  case  of  malignant 
cholera. 

At  Barr^me  the  contamination  was  due  to  the  clothes 
of  a  working  man  suffering  from  cholera,  which  were 
thrown  into  the  River  Asse.  All  the  villages  down- 
stream had  cases  of  cholera.  At  Gap,  Prades,  Cerbere, 
Perpignan,  Nantes,  etc.,  the  same  thing  was  proved  to 
occur. 

The  Hamburg  epidemic  commenced  on  the  18th 
August  1892.  By  the  29th  there  had  already  been  3400 
cases  and  1100  deaths,  due  to  the  water  of  the  Elbe, 
which  was  unfiltered,  but  was  the  only  water  utilised. 
The  city  of  Altona,  which  adjoins  Hamburg,  was  very 
little  afifected.  In  these  two  communities  it  happened 
that   one   side   of  a   street,   belonging   to   Hamburg, 


433    DYSENTERY,  CHOLERA,  AND  TYPHUS 

was  infected,   while  the  other  side,  forming  part  of   * 
Altona,  was  unaffected.     In  1913  there  were,  on  certain 
days,  in  Hamburg  more  than  1000  cases  a  day.     In 
Altona,  where  filtered  Elbe  water  was  consumed,  there 
were  only  sporadic  cases. 

The  Petrograd  epidemic  of  1908  was  due  to  drinking- 
water.  There  were  as  many  as  400  cases  daily 
(Gamaleia). 

The  epidemic  which  prevailed  in  the  outskirts  of 
Paris  in  1892  afforded  another  demonstration  of  the 
influence  of  drinking-water.  Neuilly,  Suresnes,  Saint- 
Denis,  which  were  supplied  with  water  drawn  from  the 
Seine  below  Paris,  suffered  severely.  At  Saint-Denis 
those  inhabitants  who  employed  the  water  from  an 
artesian  well  were  unaffected  (Netter). 

The  contamination  of  river  and  lake  water  is  certainly 
effected  by  sewage  and  the  washing  of  clothes.  But 
boatmen,  bargees,  etc.,  play  a  very  important  part  in 
infecting  such  waters ;  for  they  are  frequently  in- 
fected by  drinking  them,  and  they  themselves  discharge 
great  quantities  of  germs  into  the  water  if  they  are  sick 
of  cholera  or  carriers  of  the  vibrio. 

The  presence  of  a  certain  amount  of  marine  salt  is 
by  no  means  prejudicial  to  the  preservation  of  the 
vibrio  in  water.  Quite  the  contrary,  the  salt  favours 
its  multiplication,  which  is  a  point  of  great  interest, 
and  explains  the  persistence  of  the  bacillus  in  the 
estuaries  of  rivers.  At  Archangel  the  water  of  the 
Dvina  has  been  found  to  be  thus  contaminated.  We 
know,  on  the  other  hand,  that  peptonised  and  saline 
agar  is  one  of  the  best  media  for  the  isolation  of  the 
vibrio.  According  to  Parini,  sea-water  does  not  kill 
the  microbe.  He  mentions  the  case  of  two  men  who, 
at  a  time  when  no  epidemic  existed,  contracted  cholera 
as  the  result  of  falling  into  the  polluted  water  of  a 
harbour,  when  they  swallowed  a  certain  amount  of 
water.  Sanarelli,  Carapelli  (at  Palermo),  etc.,  have 
insisted  on  the  comparatively  frequent  occurrence  of 
vibrios  resembling  the  cholera  vibrio  in  river  waters, 


ETIOLOGY  OF  CHOLERA  433 

apart  from  the  existence  of  any  case  of  cholera.  There 
is  no  doubt  as  to  the  animal  or  human  origin  of  these 
microbes.  It  is,  nevertheless,  curious  that  the  exist- 
ence of  these  microbes  is  not  accompanied  by  a  simul- 
taneous choleraic  infection.  Zlatogorov  has  recorded 
the  case  of  a  Russian  student  who,  having  accidentally 
absorbed  a  bacillus  isolated  from  the  Neva,  developed 
a  choleriform  infection.  But  on  the  other  hand, 
E.  Sergent  and  L.  Negre  have  recorded  the  immunity 
of  a  town  whose  fluvial  waters  contained  a  vibrio  which 
apparently  was  the  authentic  cholera  vibrio.  There 
are  still,  therefore,  some  unknown  vibrios. 

Gosio  has  expressed  the  opinion  that  earth-worms, 
which  are  coprophagic,  might  contribute  to  the  pro- 
pagation of  the  cholera  vibrio.  He  has  found  the 
vibrio  in  the  alimentary  canal  of  earth-worms.  These 
vibrios  came  from  a  lake  from  which  Carapelle  had 
isolated  the  cholera  bacillus.  A  month  later  the 
bacillus  still  existed  in  the  intestine  of  young  earth- 
worms. According  to  Venuti,  earth-worms  and 
molluscs  retain  the  vibrio  in  their  alimentary  canals, 
but  it  becomes  attenuated. 

The  danger  of  consuming  raw  oysters  and  other  shell- 
fish results  from  the  fact  that  these  molluscs  have  lived 
in  waters  infected  by  the  cholera  vibrio,  while  preserved 
in  the  neighbourhood  of  ports  or  near  the  outfall  of 
sewers.  Oysters  feed  on  particles  of  organic  matter 
contained  in  the  water.  In  this  way  they  retain  its 
impurities  ;  they  act  as  a  kind  of  filter,  conserving  the 
vibrio  for  twelve  to  sixteen  days  (Pinzani).  Cases  of 
established  contagion,  due  to  oysters  (Geddins,  Cal- 
mette,  Rouchette,  Pottevin,  etc.)  have  been  reported 
in  Italy  and  in  France. 

Fish  living  in  contaminated  waters  may  introduce 
the  germ  into  the  body  if  they  are  eaten  raw,  or 
Insufficiently  cooked,  for  example,  as  in  Japan. 

The  transportation  of  the  microbe  has  also  been  attri- 
buted to  the  bilge-water  of  ships,  which  may  contain 
the  germ.     It  has  been  stated  that  sea-water  is  by 


434     DYSENTERY,  CHOLERA,  AND  TYPHUS 

no  means  hostile  to  the  vibrio.  Nicati  and  Rietsch, 
having  stirred  the  vibrio  into  steriUsed  water  taken 
from  the  Old  Port  of  Marseilles,  discovered  that  the 
microbe  survived  for  eighty-one  days.  Other  observers 
have  noted  its  persistence  for  two  or  three  weeks,  and 
even  for  four  months  (Piccinini).  In  1909  the  bacillus 
was  isolated  at  Gand  from  the  very  saline  bilge-water 
of  ships  hailing  from  Riga  and  Petrograd.  Water 
employed  as  ballast  may  also  contain  the  vibrio 
(Jacobsen,  of  Copenhagen).  According  to  Remlinger, 
the  spray  of  contaminated  sea-water  may  spread  or 
communicate  the  cholera  vibrio. 

It  goes  without  saying  that  if  the  drinking-water 
kept  on  board  ship  contains  the  cholera  bacillus,  it 
may  become  the  point  of  departure  of  an  epidemic 
among  the  sailors,  and  in  the  ports  at  which  the  vessel 
touches,  or  in  towns  or  villages  situated  along  the 
course  of  a  river.  The  epidemic  which  prevailed  in 
Toulon  in  1911,  attacking  the  crews  of  the  warships 
there,  was  attributed  to  this  cause  (Defressine  and 
Cazeneuve). 

With  the  exception  of  milk,  the  part  played  by 
beverages — wine,  cider,  beer,  etc. — is  inconsiderable. 
The  cholera  vibrio  is  not  robust,  and  is  easily  killed  in 
an  acid  medium,  such  as  wine.  It  does  not  survive 
longer  than  five  minutes  in  red  or  white  wine,  mixed 
with  an  equal  volume  of  water.  In  beer  it  survives 
only  for  a  few  hours.  Vinegar  and  lemon  juice  destroy 
it  very  quickly.  According  to  Metin,  infusions  of  tea, 
if  contaminated,  may  transmit  the  vibrio. 

Milk  has  often  been  condemned  as  a  source  of 
infection.  Its  pollution  may  result  either  from  dilution 
with  polluted  water,  or  to  contamination  by  a  milkman 
or  milk  maid  who  is  suffering  from  cholera  or  is  a  germ- 
carrier,  or  to  the  use  of  unclean  receptacles,  or,  lastly, 
to  flies,  living  or  dead.  We  have  already  spoken  of 
the  infection  of  milk  by  means  of  flies. 

Le  Dantec  has  recorded  the  details  of  an  epidemic 
in  which  nine  sailors  out  of  ten  contracted  cholera  after 


ETIOLOGY  OF  CHOLERA  435 

drinking  milk  diluted  with  water  from  a  pond  into 
which  the  dejecta  of  choleraic  subjects  had  been  thrown. 
The  vibrio,  as  a  matter  of  fact,  multiplies  in  milk, 
above  all  in  boiled  milk.  The  lactic  ferment  is  in- 
jurious to  it  and  kills  it.  It  readily  survives  on  the 
surface  of  butter,  in  fresh  cream,  and  on  cheese. 


CHAPTER  XIV 

PROPHYLAXIS    OF    CHOLERA 

Prophylaxis  of  Favouring  Causes, — ^Although  the  factors 
which  have  been  described  as  favouring  causes  play 
only  an  accessory  part,  their  importance  must  not  be 
disregarded  in  times  of  epidemic. 

A  moderate  diet  and  sobriety  are  useful  precautions. 
Heavy  meals  should  be  avoided,  and  the  excessive 
use  of  alcohol.  Purgatives  may  awaken  the  choleraic 
infection. 

Personal  cleanliness,  particularly  that  of  the  hands, 
is  to  be  especially  recommended.  Avoid  fatigue,  over- 
exertion, and  long  marches,  especially  in  the  heat  of  the 
day,  as  these  factors  diminish  organic  resistance  and 
increase  thirst,  thereby  augmenting  the  possibilities  or 
the  severity  of  contagion. 

Houses,  courtyards,  and  gardens  must  be  kept 
scrupulously  clean,  the  same  applying  to  barracks. 
Ventilation,  natural  lighting,  and  sunlight  are  excellent 
means  of  disinfection. 

Particular  attention  must  be  paid  to  closets,  privies, 
urinals  and  dung-hills,  which  ought  to  be  removed,  and 
manure-pits,  which  must  be  done  away  with. 

Kitchens  are  to  be  inspected,  and  everything  should 
be  destroyed,  by  fire  or  burial,  which  might  attract  flies 
and  permit  of  their  multiplication  :  ordure,  kitchen 
refuse,  organic  matter,  etc. 

When  there  is  a  danger  of  cholera  the  general  hygiene 
of  towns  demands  the  same  measures.  The  accumula-' 
tion  of  filth  must  be  avoided ;  the  flushing  of  gutters 
and  sewers  must  be  facilitated  ;  streets,  cesspools,  etc., 
must    be    cleaned.     Slaughter-houses,    butchers'    and 

436 


PROPHYLAXIS  OF  CHOLERA  437 

pork-butchers'  shops,  factories,  and  the  working-class 
quarters  should  be  carefully  inspected.  Sanitary  in- 
spectors should  visit  hotels,  restaurants,  and  wine-shops, 
above  all  in  the  neighbourhood  of  ports  and  in  in- 
salubrious quarters,  and  ensure  that  the  special  pre- 
ventive measures  which  will  presently  be  described  are 
applied. 

In  the  case  of  barracks,  the  entire  premises  should  be 
kept  in  a  condition  of  scrupulous  cleanliness.  Scrub- 
bing and  sluicing  with  plain  water,  which  favours  the 
conservation  of  the  microbe,  is  to  be  abandoned  in 
favour  of  cleaning  by  means  of  sawdust  impregnated 
with  an  antiseptic  (carbolic  acid,  lysol,  cresol). 

Dung-hills  or  muck-heaps  must  be  removed  from  the 
barracks  daily,  while  dung-pits  should  be  cleaned  out 
and  sprinkled  with  antiseptics.  It  is  useful  to  appoint 
fatigue  parties  to  clean  the  latrines  or  privies  and  their 
approaches  several  times  a  day. 

Prisons,  reformatories,  etc.,  whose  cleanliness  only  too 
often  leaves  much  to  be  desired,  must  not  be  neglected. 
In  camps,  and  in  time  of  war,  the  application  of  the 
above  measures  must  be  most  strictly  enforced. 

It  is  also  necessary  to  eliminate  from  the  diet  all 
indigestible  and  imperfectly  cooked  foods,  salt  pork, 
fresh  pork,  sausages,  meat  pies,  etc.,  which  might  be 
made  from  unwholesome  meat. 

Raw  vegetables  are  to  be  prohibited  :  salads, 
radishes,  cucumbers,  tomatoes,  etc.,  and  even  raw 
fruits.     River  bathing  must  be  stopped. 

Prophylaxis  of  Cholera  on  hoard  Warships. — The 
prophylactic  rules  to  be  followed  are  obviously  the  same 
on  board  ship  as  on  land.  Respecting  vessels  on  active 
service,  a  circular  issued  by  the  French  Ministry  of 
Marine  on  the  3rd  October  1909  prescribed  the  following 
measures  :  Healthy  vessels  touching  at  an  infected  port 
will  cast  anchor  at  a  sufficient  distance,  will  reduce  the 
term  of  their  stay  in  port,  will  avoid  mooring  at  quay- 
sides, and  will  take  the  usual  precautions  with  a  view 
to  avoiding  infection. 


438    DYSENTERY,  CHOLERA,  AND  TYPHUS 

Infected  vessels  will,  in  respect  of  themselves  and 
their  sick,  take  the  necessary  measures  of  isolation,  dis- 
infection, etc.  On  their  arrival  they  are  subjected  to 
the  medical  inspection  of  crew  and  passengers,  the  dis- 
infection of  dirty  linen,  water-closets,  etc.,  the  immedi- 
ate disembarkation  and  isolation  of  the  sick,  and  also 
of  the  healthy  passengers  and  sailors.  These  latter  are 
kept  under  supervision  for  five  days,  and  should  be 
vaccinated  against  cholera. 

Microbic  Prophylaxis. — Efforts  should  be  made  to 
attack  the  infectious  germ  wherever  it  exists  :  in  the 
patient,  in  the  carrier,  on  soiled  linen  and  underclothing, 
in  privies,  on  the  surface  of  the  soil,  in  and  about 
dwelling-houses,  in  polluted  waters,  on  food,  etc. 

The  microbic  prophylaxis  is  accordingly  extremely 
complex.  Any  negligence,  or  the  omission  to  carry 
out  any  of  the  necessary  precautions,  will  result  in  the 
spread  of  epidemic  cases.  The  vibrio  must  therefore  be 
followed,  step  by  step,  from  the  patient  or  the  carrier, 
and  we  must  seek  to  destroy  it  in  each  of  the  stages 
through  which  it  passes,  either  in  living  or  in  inert 
media.  For  this  purpose  the  aid  of  the  laboratory  is 
absolutely  indispensable  to  the  rational  prophylaxis  of 
the  disease. 

As  soon  as  the  threat  of  cholera  exists,  and,  a  fortiori, 
directly  the  first  cases  appear,  special  bacteriological 
laboratories  should  be  mobilised  for  the  examination 
of  the  first  suspected  cases.  They  should  be  amply 
equipped  with  the  necessary  appliances  for  collecting 
the  dejecta  of  suspected  patients,  and  with  the  appli- 
ances required  for  the  cultivation  and  incubation  and 
expert  examination  of  cultures. 

On  the  precise  diagnosis  of  the  first  cases  the  fate  of 
an  epidemic  will  very  often  depend.  The  verification 
of  the  reactions  of  inmiunity  in  the  blood  of  the  persons 
affected  is  not  so  valuable  as  the  discovery  of  the  vibrio. 
It  is  of  little  use  save  as  a  means  of  retrospective 
diagnosis. 

In  the  acute  forms  of  cholera,  above  all  when  the  rice- 


PROPHYLAXIS  OF  CHOLERA  439 

like  grains  are  observed,  the  cultivation  of  the  stools  in 
appropriate  media  readily  yields  cultures  of  the  vibrio. 
This  is  not  true,  however,  of  ill-defined  cases,  or  of  slight 
diarrhoeas  ;  it  is  therefore  necessary  to  practise  culti- 
vations of  the  stools  in  these  latter  cases,  as  in  the  more 
authentic  cases. 

After  death  the  autopsy  and  the  bacteriological 
examinations  should  be  made  as  promptly  as  possible. 
The  vibrio  is  found  in  the  exudate  which  covers  the 
mucous  membrane  of  the  intestine,  mingled  with 
numerous  epithelial  cells. 

It  should  be  remembered  that  the  cholera  vibrio 
comprises  a  fairly  large  number  of  races,  which  differ  in 
their  dimensions — that  is,  in  their  length  and  thickness  ; 
their  form  (some  are  rectilinear  and  rod-like,  others 
ovoidal,  almost  like  cocci) ;  and  their  motility,  which 
may  even  be  lacking. 

Cultivations  should  be  made  with  one  to  five  cubic 
centimetres  of  medium,  and  sometimes  with  much 
larger  quantities,  distributed  in  a  certain  number  of 
receptacles  containing  50  centigranames  of  peptonised 
water.  The  examination  should  be  made,  at  the  latest, 
six  to  twelve;  hours  later.  Simultaneously  cultures 
may  be  made  in  a  mixture  of  agar  and  blood  made 
alkaline  with  potassium.  It  must  be  remembered 
that  B.  coli,  certain  cocci,  and  B.  pyocyaneus 
are  also  capable  of  multiplying  on  Dieudonne's  agar. 
It  is,  in  general,  therefore,  preferable  to  enrich  the 
medium  previously,  rather  than  to  commence  the 
bacteriological  analysis  by  cultivations  made  in  pepton- 
ised water,  before  making  discriminative  cultivations 
on  a  solid  medium. 

The  specific  verification  of  the  microb^  isolated  by 
agglutination  iri  vitro,  the  test  of  injection  into  the 
peritoneum  of  an  immunised  guinea-pig,  the  indol 
reaction,  and  Bordet's  reaction,  will  .complete  the  in- 
vestigation. 

The  permanent  Committee  of  the  International 
Bureau  of  Hygiene,  in  1911,  confided  to  M.  Pottevin  the 


440     DYSENTERY,  CHOLERA,  AND  TYPHUS 

preparation  of  a  report  upon  the  bacteriological  diag- 
nosis of  cholera.  Italy,  in  1915,  published  information 
of  the  same  nature,  indicating,  at  the  same  time,  the 
means  of  removing  and  dispatching  suspected  matter. 
The  latter  (50  centigrammes)  is  placed  in  a  glass 
receptacle,  as  are  fragments  of  soiled  linen.  After 
death  about  six  inches  of  that  part  of  the  ileum  which 
lies  immediately  above  the  ileo-caecal  valve  is  re- 
moved, between  ligatures.  This  material  is  enclosed 
in  receptacles  of  thick  glass,  sterilised  by  boiling,  and 
well  stoppered. 

Administrative  dispositions  and  sanitary  regulations 
have  been  adopted  by  European  countries  to  prevent 
the  introduction  of  cholera,  and  to  combat  its  propaga- 
tion and  its  sequelae,  during  the  present  war.  Sweden 
(Royal  ordinance  of  the  9th  of  November  1915),  Holland 
(the  15th  of  November  1915),  etc.,  have  decreed  the 
precautions  necessary  to  protect  themselves  against 
this  disease,  which  has  been  prevalent  among  the 
Austrian,  Turkish,  and  other  troops,  while  it  was  im- 
ported into  Italy  by  Austrian  prisoners. 

Consequently,  a  bacteriological  diagnosis  of  the  first 
case  or  cases  should  always  be  established.  Without 
waiting  for  the  result  of  the  expert  inquiry,  all  sick 
and  suspected  persons  should  be  isolated,  and  such 
isolation  should  be  extended  to  orderlies  and  nurses  of 
either  sex. 

The  case  must  be  immediately  notified  by  the 
physician,  and  access  to  such  cases  should  be  forbidden 
to  any  other  persons  than  the  physician. 

Isolation  premises  should  be  sufficiently  removed 
from  other  buildings,  and  must  be  provided  with 
special  closets  and  a  special  drainage  system. 

Nurses  and  orderlies  should  be  vaccinated  against 
the  disease.  The  sick  person's  clothes  and  underclothes 
should  be  placed  in  a  sack  for  disinfection  and  sent  to 
the  oven. 

If  disinfection  cannot  be  effected  immediately  clothes 
should  be  plunged  into  a  vat  containing  water  to  which 


PROPHYLAXIS  OF  CHOLERA  441 

Javel's  solution  has  been  added,  in  such  proportions 
that  the  mixture  contains  0*5  centigrammes  of  chlorine 
per  litre.  Linen  polluted  by  alvine  evacuations  and 
vomit  must  be  the  object  of  special  precautions  ;  such 
materials  must  be  handled  with  tongs  or  hands  protected 
by  rubber  gloves.  Boiling  lye,  or  even  boiling  water 
merely,  kills  the  cholera  vibrio  instantaneously. 

Bedroom  utensils,  basins,  slop-pails,  spittoons,  etc., 
are  to  be  disinfected  with  sulphate  of  copper  (10  per 
cent.),  or  with  powdered  chloride  of  lime,  or  Javel's 
solution,  1  in  50.  The  dejecta  and  the  vomit  of  the 
patient  should,  if  possible,  be  incinerated  after  being 
subjected  to  the  action  of  the  above-mentioned  anti- 
septics. They  must  not  be  deposited  in  the  neighbour- 
hood of  wells  or  water-courses,  or  in  gardens,  or  on 
dung-heaps,  etc.,  etc. 

Floors,  walls,  etc.,  subject  to  contamination  are  dis- 
infected with  boiling  water  and  washing  soda. 

The  usual  articles  used  by  the  patient- — bowls, 
spoons,  plates,  metallic  drinking-cups,  etc. — should  be 
placed  in  a  wire  basket  and  plunged  into  boiling  water 
made  alkaline  with  washing  soda. 

The  patient  should  be  kept  scrupulously  clean,  and 
disinfected  with  a  solution  of  cresol  or  dilute  Javel's 
solution,  his  hands  being  frequently  washed.  Cholera 
cases  should  be  placed  in  a  special  ward  and  tended  by 
a  special  staff,  the  members  of  which  have  been  vaccin- 
ated against  cholera.  Precise  instructions  as  to  avoid- 
ing contagion,  as  to  washing  the  hands,  wearing  rubber 
gloves,  and  effecting  frequent  changes  of  blouses, 
etc.,  should  be  given.  Pencils,  pen-holders  and  pins 
must  not  be  placed  in  the  mouth,  and  no  one  must 
eat  or  smoke  in  the  cholera  ward,  but  in  a  separate 
apartment,  after  a  change  of  protective  clothing  and 
disinfection  of  the  hands. 

In  country  districts  the  supervision  of  the  patient 
and  those  about  him,  and  the  application  of  the  above- 
mentioned  measures  of  hygiene,  are  only  too  often  im- 
perfectly carried  out.     The  dispersion  of  faecal  matter 


442    DYSENTERY,  CHOLERA,  AND  TYPHUS 

over  the  soil,  in  back  yards,  farmyards,  roads,  gardens, 
dung-hills,  etc.,  favours  the  diffusion  of  the  vibrio.  It 
is  therefore  necessary  to  leave  physicians  or  qualified 
assistants  in  such  localities,  whose  business  it  will  be  to 
ensure  that  these  rules  are  observed. 

The  same  measures  of  disinfection  are  to  be  applied, 
in  times  of  epidemic,  to  the  dejecta  of  any  persons 
suffering  from  even  light  forms  of  diarrhoea. 

The  stools  of  patients  who  have  recovered  are  dealt 
with  in  the  same  manner,  as  long  as  the  appropriate 
cultivations  reveal  the  vibrio  in  them. 

Dead  bodies  should  as  quickly  as  possible  be  wrapped 
in  sheets  which  are  strongly  impregnated  with  cresol, 
and  should  at  once  be  placed  in  water-tight  coffins 
with  a  large  quantity  of  saw-dust  impregnated  with 
cresol. 

All  doubtful  or  uncertain  cases  must  be  subjected  to 
bacteriological  examinations  of  the  stools. 

Identical  precautions  should  be  taken  in  the  case  of 
ships  carrying  cholera  patients,  or  suspected  persons, 
or  in  the  case  of  ships  hailing  from  contaminated 
ports.  The  International  Conferences  of  Constantinople, 
Vienna,  and  Paris  have  issued  regulations  as  to  the 
hygienic  and  administrative  measures  designed  to 
protect  ports  of  arrival,  and  to  prevent  the  spread  of 
cholera.  To  this  end,  when  an  epidemic  threatens, 
lazarettos  are  established  in  the  ports  of  arrival.  The 
above-named  conferences  have  decreed  that  passengers 
and  crews  should  be  inspected  and  placed  in  quarantine. 

Pilgrimages  to  Mecca  are  prohibited.  Lazarettos  are 
established  in  Egypt  to  stop  travellers  and  provide 
the  sick  with  attention.  Similar  measures  are  taken 
on  the  frontier  and  at  the  railway  stations  at  which 
travellers  coming  from  contaminated  countries  arrive. 

It  should  be  remarked  that  the  above  measures 
relative  to  the  protection  of  frontier  ports  and  stations, 
although  of  the  greatest  service,  are  not  nowadays  re- 
garded as  indispensable.  We  cannot  guard  absolutely 
against  cholera  by  closing  the  frontiers.     Healthy  germ- 


PROPHYLAXIS  OF  CHOLERA  443 

carriers,  convalescents,  and  the  water  of  rivers  may  effect 
the  spread  of  the  disease.     So  may  imported  food-stuffs. 

Accordingly  the  quarantine  system  has  been  re- 
placed in  the  principal  ports  by  the  careful  medical 
inspection  of  passengers,  and  their  medical  and  ad- 
ministrative supervision  in  whatever  localities  they  go 
to.  International  prophylaxis  has  everywhere  adopted 
very  similar  precautions. 

In  France  the  notification  of  cholera  is  compulsory. 
A  decree  of  the  28th  of  August  1909  requires  that  a 
general  sanitary  supervision  shall  be  exercised  in  respect 
of  ever}^  traveller,  package,  or  other  object  coming  from  a 
contaminated  region.  Sufferers  from  cholera  are  detained 
in  a  special  hospital.  Suspected  persons  are  isolated  for 
a  period  which  must  not  exceed  five  days.  The  other 
travellers  receive  a  sanitary  passport,  Which  they  must 
present  to  the  mayor  of  the  commune  within  twenty- 
four  hours  of  their  arrival.  They  are  then  subjected 
to  a  special  sanitary  supervision  for  five  days,  and  are 
visited  in  their  place  of  domicile,  and,  if  they  are  found 
to  be  infected,  or  regarded  as  suspect,  they  are  immedi- 
ately isolated.  In  Paris  they  must  notify  any  change  of 
address  to  the  prefecture  of  police  or  the  mayor  of  their 
arrondissement.  All  their  luggage  is  officially  disin- 
fected. The  importation  of  soiled  linen,  clothing,  soiled 
bedding,  rags,  fruits,  and  vegetables  is  prohibited. 

It  is  to  be  noted  that  these  precautions  do  not  take 
into  account  the  possibility  of  contagion  due  to  the 
carriers  of  germs,  and  the  danger  which  these  constitute. 
On  the  other  hand,  the  period  of  five  days  allowed  for 
medical  supervision  is  assuredly  too  short  when  it  is  not 
completed,  as  is  usually  the  case,  by  a  bacteriological 
examination  of  the  dejecta.  The  incubation  period  of 
cholera  may,  as  a  matter  of  fact,  exceed  five  days. 

To  the  above-mentioned  precautions  it  is  as  well  to 
add  the  special  supervision  of  vagrants,  nomads,  pedlars, 
and  itinerants.  As  regards  inland  navigation,  the 
same  medical  supervision  should  be  exercised  in  respect 
of  boatmen,  bargees,  etc. 


444     DYSENTERY,  CHOLERA,  AND  TYPHUS 

During  epidemics,  fairs,  public  meetings,  etc.,  should 
be  prohibited,  as  these  multiply  or  prolong  the  causes 
of  interhuman  contagion.  Lastly,  the  practice  of 
vaccination  against  cholera,  on  as  extensive  a  scale  as 
possible,  should  be  urgently  recommended. 

MacLaughlin,  in  order  to  facilitate  the  search  for 
the  cholera  vibrio  in  the  case  of  travellers  arriving  from 
countries  where  cholera  is  suspected,  has  recommended 
that  they  should  be  dosed  with  sulphate  of  magnesia, 
in  the  morning,  on  an  empty  stomach  ;  with  the  excep- 
tion of  children  and  persons  suffering  from  diarrhoea. 
Under  these  conditions  he  made  2000  examinations  in 
Boston  and  Providence.  This  procedure  is  said  to  be 
preferable  to  the  removal  of  matter  from  the  rectum  by 
means  of  a  plug  of  cotton  wool.  The  administration  of 
a  saline  purgative  causes  the  reappearance  of  the  vibrio 
in  the  excreta  of  convalescents  or  healthy  carriers. 
•  •  •  ..  •  .  • 

The  prophylaxis  relating  to  contagion  by  means  of 
intermediate  agents,  living  or  inanimate  (indirect  con- 
tagion), deals  more  particularly  with  articles  of  food, 
drinking-water,  flies,  clothing,  underclothing,  linen, 
the  soil,  and,  generally,  anything  that  may  have  been 
contaminated  by  the  fgecal  matter  of  cholera  patients 
or  germ-carriers,  and  anything  that  may  have  been 
employed  as  a  receptacle  of  such  faecal  matter. 

Everything  that  may  cause  indigestion  or  diarrhoea, 
or  may  introduce  the  cholera  vibrio,  must  be  avoided  : 
green  fruits,  cucumbers,  oysters,  shell-fish,  high  meat  or 
game,  etc.     The  use  of  purgatives  is  dangerous. 

In  times  of  epidemic  cooked  foods  should  be  con- 
sumed—that is,  foods  disinfected  by  heat — while  those 
foods  which  will  not  bear  cooking  (cheese,  etc.)  should 
be  effectually  protected  from  contamination  by  flies, 
which  is  sometimes  difficult,  and  from  germ-carriers, 
which  is  still  more  difficult.  The  employment  of  safes, 
dish-covers  of  wire  gauze,  napkins,  etc.,  and  the 
mechanical  prophylaxis  of  kitchens,  dining-rooms,  mess- 
rooms,  hospital  wards,  etc.,  against  the  access  of  flies, 


PROPHYLAXIS  OF  CHOLERA  445 

by  means  of  the  fitting  of  screens  of  wire  gauze  or 
mosquito-netting  in  doors  and  windows,  will  prove  of 
the  greatest  service. 

The  disinfection  of  latrines,  privies  and  their 
approaches,  by  means  of  chloride  of  lime,  protects  them 
from  the  vibrios  and  the  flies  which  distribute  them. 

Flies  may  be  destroyed  by  means  of  fly-traps,  fly- 
papers, and  powdered  pyrethrum,  scattered  at  night  over 
shelves  and  tables,  and  by  means  of  saucers  containing 
a  little  beer,  to  which  a  fiftieth  part  of  formalin  has 
been  added. 

It  is  needless  to  insist  that  in  times  of  epidemic  it  is 
necessary  to  drink  no  water  that  has  not  been  carefully 
purified.  Sterilisation  by  boiling  constitutes  a  perfect 
guarantee  of  safety.  Extremely  susceptible  to  anti- 
septics, the  cholera  vibrio  is  killed  in  a  few  minutes  by 
chlorine,  in  the  proportion  of  1  milligramme  to  1  litre 
of  water.  Hence  the  value  of  sterilisation  by  means  of 
Javel's  solution,  or  the  special  tabloids  of  hypochlorite 
of  calcium  (Vincent  and  Gaillard).  The  Lambert 
process  also  affords  an  excellent  means  of  destroying 
the  cholera  vibrio. 

The  prophylaxis  of  cholera  in  barracks,  camps,  and 
cantonments,  and,  lastly,  among  troops  in  the  field,  calls 
for  the  same  general  measures  as  those  which  have  just 
been  indicated.  In  time  of  war,  it  cannot  be  denied 
that  this  prophylaxis  would  offer  considerable  practical 
difficulties  were  it  not  that  specific  vaccination  against 
cholera  affords  a  real,  though  not  an  absolutely  com- 
plete, protection. 

An  early  diagnosis  must  be  made  of  every  case  of 
cholera,  and,  without  waiting  for  results,  the  patient  or 
suspected  person  should  immediately  be  isolated,  and 
the  premises  or  quarters  involved,  togeth,er  with  the 
latrines,  should  be  immediately  disinfected.  All  benign 
cases  must  be  made  the  object  of  bacteriological  ex- 
amination, and  patients  must  not  leave  hospital  until 
two  bacteriological  examinations  of  the  stools  have  been 
made,  at  an  interval  of  a  week. 


446    DYSENTERY,  CHOLERA,  AND  TYPHUS 

Ambulance  cars  should  be  disinfected  (with  boihng 
water  and  washing  soda  or  Javel's  sohition,  the 
stretchers  and  canvas,  etc.,  being  washed). 

The  bacteriological  laboratories  should  also  under- 
take the  bacteriological  analysis  of  water  supplies. 

In  France,  in  time  of  peace,  a  special  delegate, 
appointed  by  the  Prefect  and  approved  by  the  Minister 
of  the  Interior,  is  instructed  to  place  himself  in  com- 
munication with  the  chief  officers  of  the  Army  Medical 
Service  in  the  fortresses,  hospitals  and  infirmaries,  with 
a  view  to  taking  all  prophylactic  measures  in  the  inter- 
ests both  of  the  army  and  the  civil  population. 

Public  water-closets,  whether  free  or  otherwise, 
should  be  inspected  and  disinfected.  Urban  disinfecting 
stations  should  be  created,  while  disinfecting  appliances 
and  automobile  ovens  should  be  placed  at  the  disposal 
of  small  towns  and  country  districts. 

A  public  notice  might  usefully  be  posted  up,  indicat- 
ing the  principal  ways  in  which  cholera  is  propagated, 
the  part  played  by  the  dejecta  of  cholera  patients  and 
of  certain  healthy  subjects,  the  part  played  by  water 
(insisting  on  the  point  that  it  is  not  the  only  agent  of 
transmission),  and  the  necessity  of  notifying  the  medical 
or  sanitary  authorities  in  cases  of  .suspicious  illness, 
etc.  The  deposition  of  faecal  matter  in  farmyards, 
stables,  manure-pits,  roads,  and  lanes  must  be  forbidden. 
The  exportation  of  clothing,  linen,  rags,  etc.,  from 
districts  in  which  cholera  is  prevalent  should  also  be 
prohibited,  unless  these  articles  have  been  subjected  to 
disinfection  by  steam  under  pressure. 

Specific  Prophylaxis  :  Vaccination  against  Cholera. — 
Vaccination  against  cholera  constitutes  at  the  present 
time  a  really  efficacious  method  of  protection  against 
the  disease.  It  was  first  practised  in  1885,  by  Ferran, 
in  Spain.  This  physician  discovered  that  guinea-pigs 
which  had  escaped  death  from  infection  due  to  the 
vibrio  were  protected  against  a  deadly  dose  of  virus. 
He  cultivated  the  vibrio  in  bouillon  at  a  temperature 
of  37°  C.  and  injected  living  cultures  of  the  microbe. 


PROPHYLAXIS  OF  CHOLERA  447 

Haffkine  inoculated  the  vibrio  into  the  peritoneum 
of  the  guinea-pig,  and,  after  passing  it  through  several 
animals,  which  increased  its  virulence,  lie  cultivated 
it  in  bouillon,  in  large,  well -ventilated  flasks,  in  which 
it  became  attenuated.  It  was  this  culture  which  he 
inoculated  as  vaccine. 

Vaccine  sterilised  by  heating  to  56°  or  60°  C.  (130° 
or  140°  F.)  has  been  employed  in  Russia,  Germany, 
Greece,  Italy,  Serbia,  etc. 

Besredka  has  recommended  an  anti-cholera  vaccine 
sensitised  by  the  same  method  as  that  which  he  em- 
ployed for  anti-typhoid  vaccine. 

Vincent  has  prepared  and  employed,  in  France, 
Serbia,  etc.,  an  anti-cholera  vaccine  sterilised  by  ether. 
This  vaccine  is  prepared  with  five  races  of  vibrios, 
derived,  as  far  as  possible,  from  the  countries  in  which 
cholera  is  prevalent.  The  vibrio  is  killed  in  less  than 
one  minute  by  the  action  of  ether. 

These  vaccines  afford  experimental  protection  against 
the  subcutaneous,  or  even  intra-peritoneal,  injection  of 
extremely  virulent  vibrios. 

In  man  the  injection  of  Ferran's  anti-cholera  vaccine, 
which  necessitates  one  or  two  repetitions  of  the  in- 
jection, produces  an  intense  local  reaction  (pain, 
oedema,  redness,  fever),  and  a  general  reaction  (fever, 
etc.),  and  sometimes  diarrhoea,  lasting  one  to  three 
days. 

Haffkine  injected  under  the  skin  of  the  flank  -^^  or 
4q  of  an  attenuated  culture  made  on  agar.  Three  to 
eight  days  later  he  injected  the  same  dose  of  fixed  and 
exalted  virus.  Later  Haffkine  employed  the  latter 
exclusively. 

Powel  inoculates  in  one  injection  |^  of  a  culture  on 
agar  of  Haffkine's  exalted  virus.  Sterilisation  by  heat 
and  antiseptics  (carbolic  acid),  "  without  destroying 
the  vaccinating  property  of  the  Haffkine  vaccines, 
diminishes  it  considerably  "  (Salimbeni). 

Between  April  and  October,  1885,  Ferran  adminis- 
tered 150,000  preventive  inoculations  to  50,000  people. 


448    DYSENTERY,  CHOLERA,  AND  TYPHUS 

With  remarkable  patience  and  perseverance,  Haff kine, 
between  April,  1893,  and  September,  1895,  vaccinated 
42,197  persons  by  means  of  nearly  70,000  injections. 
The  vaccine  was  living.  The  number  of  subjects  vaccin- 
ated by  his  method  has  been  considerably  increased 
since  then.  The  vaccinations  have  been  carefully 
checked,  and  their  results  compared  with  the  morbidity 
of  persons  subjected  to  similar  conditions  of  infection. 
In  each  locality  one-half  only  of  the  inhabitants  were 
vaccinated,  the  other  half  serving  as  a  control.  The 
results  testified  to  an  efficacy  which  was  not  absolute, 
but  was  genuinely  considerable.  The  immunity,  it 
was  said,  might  continue  for  twelve  to  fourteen 
months, 

Aldo  Castellani,  in  1909,  adopted  the  employment  of 
living  cultures  as  vaccine,  a  method  which  Ch.  NicoUe 
has  also  employed.  For  the  first  injection  he  recom- 
mends Wright's  dead  vaccine. 

The  employment  of  vaccine  sterilised  by  heating  has 
been  recommended  in  Germany.  Two  milligrammes 
of  a  culture  made  on  agar  (a  platinum  loopful)  is  in- 
jected, diluted  with  physiological  water,  and  with  the 
addition  of  carbolic  acid.  The  injection  is  accompanied 
by  considerable  local  and  general  reaction. 

For  four  days  there  is  said  to  be  a  negative  phase, 
with  predisposition  to  infection  (Testi). 

Cawadias  has  stated  that  during  the  epidemic  which 
broke  out  in  the  Greek  Army  at  the  time  of  the  last 
Balkan  War,  his  cholera  patients  included  : 

82*5  per  cent,  of  non- vaccinated  subjects 
10 '6        ,,        of  incompletely  vaccinated  subjects 
6*7        ,,        of  completely  vaccinated  subjects. 

Among  the  non- vaccinated  there  were  21  per  cent, 
of  deaths ;  among  the  vaccinated  patients,  2  per 
cent. 

Arnaud  has  published  similar  data. 

In  Russia  an  official  circular  appearing  in  1909 
recommended  vaccination  against  cholera. 


PROPHYLAXIS  OF  CHOLERA  449 

Three  injections  were  made,  tlie  first  consisting  of 
0-5  to  1  c.c.  ;  the  others  of  2  and  3  c.c.  One  should 
avoid  vaccinating  persons  suffering  from  cholera,  persons 
suffering  from  febrile  complaints,  and  weak  or  anaemic 
persons. 

About  this  time  Zverev  collected  and  classified  the 
observations  of  a  large  number  of  hospitals  :  28,996 
persons  were  given  preventive  injections.  The  number 
of  injections  was  only  53,162.  The  reaction  caused 
by  the  injection  was  slight  in  58  per  cent,  of  these, 
of  medium  intensity  in  32  per  cent,  (involving 
lassitude,  vertigo,  severe  headache,  nausea,  colic, 
diarrhoea),  and  severe  in  10  per  cent,  (involving 
violent  headache,  vomiting,  frequent  diarrhciea,  pain, 
high  fever,  and  incapacity  to  work  for  several 
days). 

As  regards  the  immunising  effects,  only  twelve  persons 
contracted  cholera.  In  addition  to  these,  twelve 
persons  fell  ill  one  to  three  days  only  after  vaccination  ; 
the  injections,  therefore,  had  no  abortive  action  on  the 
cholera. 

Two  suffered  from  diarrhoea  of  a  choleraic  type,  12 
and  15  days  after  an  injection,  and  rapidly  recovered. 
One  nurse  had  cholera  2  months  and  5  days  after  the 
second  injection,  and  recovered.  A  woman  of  forty- 
four  developed  cholera  30  -  days  after  the  second  in- 
jection, and  died. 

The  immunity  conferred  by  vaccination  has  in  general 
been  high. 

Kasch  Kadarrov  has  published  an  essay  giving  par- 
ticulars of  the  vaccination  of  16,011  persons  by  means 
of  30,078  injections.  Of  these  persons  6352  received 
one  injection  (that  is,  39-7  per  cent.)  ;  5251  received 
two  injections  (32-8  per  cent.)  ;  and  4408  received 
three  injections  (27*5  per  cent.). 

34-6  of  those  vaccinated  suffered  reactions  :  severe 
in  13-5  per  cent.,  of  mediimi  intensity  in  32-4  per  cent., 
and  slight  in  54-1  per  cent. 

The  fact  of  immunity  was  thoroughly  established. 


450     DYSENTERY,  CHOLERA,  AND  TYPHUS 

but  only  several  days  after  the  injections.     The  dura- 
tion of  the  immunity  was  brief  (a  few  months). 

It  is  estimated  that  the  duration  of  the  immunity 
conferred  by  vaccine  steriUsed  by  heating  is  not  in 
general  more  than  six  months. 

Aaser,  of  Christiania,  made  an  anti-cholera  vaccine 
(by  heating)  with  a  very  virulent  race  of  vibrios,  and 
vaccinated  thirty-one  persons,  nearly  all  of  whom 
exhibited  local  and  general  reactions. 

In  the  Val-de-Grace  laboratory  an  anti-cholera 
vaccine  is  prepared  with  ether.  This  vaccine  is  poly- 
valent— that  is,  it  is  prepared  with  five  races  of  vibrio, 
obtained  from  countries  actually  infected  (Galicia, 
India,  etc.).  This  vaccine  has  been  injected  into 
several  thousands  of  soldiers  in  France,  Serbia,  etc., 
and  gives  rise  to  no  local  or  general  reaction.  It  causes 
neither  swelling,  nor  pain,  nor  fever,  and  may  be  in- 
jected, as  it  is  so  readily  tolerated,  into  any  individual, 
without  any  counter-indication  save  incipient  cholera. 
Two  injections  are  given  at  five  days'  interval :  one  of 
2  c.c.  and  the  other  of  2-5  c.c. 

The  Serbian  troops  were  vaccinated  by  means  of  two 
vaccines,  one  prepared  by  means  of  heating  and  one 
with  ether.  The  result  was  an  excellent  degree  of 
protection. 

The  same  vaccines  were  employed  in  the  Italian 
Army,  cholera  having  been  imported  by  the  Austrian 
prisoners  ;  but  the  disease  was  very  quickly  suppressed. 

In  the  German  Army  vaccination  against  cholera  has 
been  practised  systematically  beginning  a  few  months 
after  the  commencement  of  the  war. 

We  possess  certain  data  as  to  the  vaccination  of  the 
Austrian  troops  in  Cracow,  where  cholera  was  preval- 
ent. The  mortality  among  the  non- vaccinated  was 
50  per  cent.  ;  among  the  vaccinated,  6-5  per  cent.  The 
vaccinated  subjects  developed  a  fairly  large  number  of 
slight  forms  of  cholera.  Vaccination  effected  during 
incubation  or  even  in  the  initial  stage  of  cholera  does 
not  appear  to  have  produced  any  evil  effects. 


PEOPIIYLAXIS  OF  CHOLERA  451 

INIoreschi  and  Marcora  have  recommended  intra- 
venous vaccination,  in  preference  to  subcutaneous 
vaccination.  The  dose  injected  is  0-1  to  0-3  of  an 
ordinary  platinum  loopful,  instead  of  six  loopfuls  (nine 
milliards  of  vibrios)  injected  under  the  skin. 


PART  /.—CLINICAL   SURVEY 

CHAPTER  XV 

SYMPTOMATOLOGY 

Typhus,^  an  acute  infectious  malady,  without  special 
anatomo-pathological  lesions,  the  specific  agent  of 
which  is  not  yet  known,  is  characterised  by  a  con- 
tinuous fever,  lasting,  on  an  average,  a  fortnight,  and 
by  morbid  symptoms  which  are  chiefly  nervous  and 
respiratory.  One  of  its  symptoms,  and  the  most  con- 
stant, is  the  appearance,  during  the  first  days  of  the 
disease,  of  a  characteristic  exanthem. 

The  clinical  development  of  typhus  consists  of  four 
periods  : 

1.  The  period  of  incubation. 

2.  The  period  of  invasion. 

3.  The  period  of  eruption. 

4.  The  period  of  termination. 

1.  Period  of  Incubation. — The  duration  of  the  period 
of  incubation  varies  from  5  to  21  days.  According  to 
Jcanneret-Minkine  it  averages  8  days  ;- according  to 
V.  Bue,  10  days  ;  according  to  A.  Netter,  11  days. 
Marsh  and  Netter  have  reported  cases  where  in- 
vasion followed  almost  immediately  upon  infection. 
In  general,  this  period  is  not  marked  by  any  indication 
which  particularly  draws  attention  to  it.  Toward 
the  end,  however,  one  may  note  certain  digestive  dis- 
orders (a  condition  of  nausea  and  anorexia),  hea'dache, 
lassitude   and   vertigo,   while   the   disposition   of  the 

^Synonyms:  Exanthemalic  typhus,  typhus  petechialis,  "spotted 
typhus,"  "  camp  typhus,"  etc. 

453 


454     DYSENTERY,  CHOLERA,  AND  TYPHUS 

patient  seems  changed.  The  temperature  is  99*5°  F. ; 
the  pulse  eighty  beats  to  the  minute.  On  the  follow- 
ing day  the  headache  is  more  violent,  the  anorexia 
more  complete.  The  temperature  rises  to  100-2°. 
The  patient  already  wears  a  jaded  expression,  which 
bears  no  relation  at  all  to  his  condition.  He  complains, 
often  enough,  of  sharp  pains  in  the  limbs,  pains  in  the 
spine,  headache,  and  vertigo,  with  buzzing  or  humming 
in  the  ears,  during  the  days  which  immediately  precede 
the  first  appearance  of  the  symptoms. 

2.  The  Period  of  Invasion. — Sometimes  after  two  or 
three  days  of  these  prodromes,  but  oftener  quite 
suddenly,  the  patient  is  attacked  by  a  violent  and 
peculiar  fit  of  shivering,  an  excruciating  headache, 
frequent  vomiting,  and  epistaxis,  the  persistence  and 
profusion  of  which  alarm  those  who  witness  it,  some- 
times necessitating  plugging  (Bue).  The  temperature 
rises  to  102°,  and  may  reach  104°  or  105° ;  the  pulse 
is  rapid,  100  to  120  beats  per  minute.  The  respira- 
tion is  accelerated,  and  there  is  cough,  with  signs  of 
slight  bronchitis.  The  face  is  congested  and  the  con- 
junctivce  injected,  and  a  muco-purulent  discharge  is 
sometimes  observed.  The  eyelids  are  tumefied. 
Sometimes,  from  the  commencement,  the  patient  is 
violently  delirious.  The  tongue  is  coated.  The 
phar^Tix  is  inclined  to  redness.  The  epigastric  region 
is  painful  upon  pressure,  and  the  patient  is  usually  con- 
stipated ;  the  abdomen  is  not  painful.  Diarrhoea  is 
not  exceptional,  however,  and  is  accompanied  by 
abdominal  rumbling  and  pain  provoked  by  pressure. 
Combemale  has  reported  cases  of  choleriform  diarrhoea. 
The  urine,  scanty,  and  dark  in  colour,  contains  albumin. 
The  patient  is  apathetic.  His  sleep  is  disturbed,  in- 
terrupted by  dismal  dreams  ;  sometimes  there  is  even 
complete  insomnia,  the  patient  being  unable  to  obtain 
even  ten  or  fifteen  minutes'  rest.  Narcotics  are  gener- 
ally powerless  to  afford  relief  (H.  de  Brun). 

3.  The  Period  of  Eruption. — From  the  fourth  or  fifth 


SYMPTOMATOLOGY  455 

day  (Netter,  Jeanneret-Minkine,  Escalier,  etc.)  the 
exanthem  of  typhus  appears,  an  exanthem  which  is 
not,  however,  constant,  and  which  may  be  lacking  in 
one-tenth  or  one-twentieth  of  the  cases  observed 
(Netter).  It  commences  on  the  trunk-;  it  should  be 
looked  for  first  of  all  under  the  armpits,  on  the  shoulders, 
then  in  the  region  of  the  epigastrium,  and  on  the  thorax  ; 
finally,  on  the  limbs  and  the  abdomen,  where  the  erup- 
tive elements  are  sometimes  very  numerous.  The 
eruption  presents  two  different  aspects,  which  differ 
greatly.  At  certain  points  the  patient's  skin  is 
sprinkled  with  marblings,  due  to  the  appearance,  under 
the  epidermis,  of  very  fine,  pale,  irregular  spots.  But 
the  eruption  which  occurs  with  by  far  the  greater  fre- 
quency consists  of  spots  which  present  no  relief,  or  very 
little,  yet  which  are  sometimes  papular,  with  rounded 
but  ill-defined  contours.  These  spots  are  at  first  rose- 
coloured  or  reddish,  but  they  afterwards  assume  a 
livid,  bluish  tint.  Their  size  varies  from  that  of  a  small 
pin's  head  to  that  of  a  large  lentil.  Often  isolated,  they 
may,  however,  be  confluent,  and  their  outlines  then 
become  irregular  and  indented. 

On  their  appearance  the  spots  disappear  for  the 
moment  on  pressure,  like  the  rose-coloured,  lenticular 
spots  of  typhoid,  but  two  or  three  days  later  they  are 
surrounded  by  a  very  pale  bluish -grey  halo.  If  they 
were  raised  they  now  subside.  It  seems  as  though  the 
skin  had  suffered  a  slight  contusion  at  this  point  : 
slight,  but  sufficient  to  produce  a  tiny  patch  of  ecchy- 
mosis,  which  no  longer  disappears  under  pressure.  This 
petechial  aspect  may  not  be  presented  by  all  the  spots. 
With  moderate  frequency  (in  10  per  cent,  only  of  the 
cases  occurring  in  an  epidemic  observed  by  Jeanneret- 
Minkine  during  the  present  war),  the  spots  undergo  a 
hsemorrhagic  transformation  ;  they  are  then  completely 
reminiscent  of  the  spots  of  purpura.  They  are  first 
observed  in  the  region  of  the  back  and  the  tracts 
exposed  to  continuous  pressure  (Escalier).  The  typhus 
spots  persist,  on  an  average,  for  five  to  ten  days.    Most 


456      DYSENTERY,  CHOLERA,  AND  TYPHU8 

of  them  disappear  without  leaving  any  traces,  but 
others  reveal  their  position,  sometinies  until  the  end  of 
the  convalescent  period,  by  a  bluish  tinge  or  a  slight 
pigmentation  of  the  skin. 

The  eruption  of  typhus  sometimes  appears  very  early, 
and  is  also  extremely  fugitive.  It  may  he  confined^ 
even  in  fatal  cases,  to  a  few  spots,  lightly  marked,  which 
sometimes  have  to  be  carefully  sought  for  (H.  Vincent). 
It  may  even  be  absent  in  children  under  fifteen 
years  of  age.  The  spots  may  become  more  visible,  or 
assume  their  characteristic  aspect,  after  washing  the 
arm  with  soap,  and  then  tying  a  ligature  round  the  root 
of  the  limb.  They  should  be  sought  on  the  palm  of 
the  hand,  which,  according  to  some  writers,  is  their 
favourite  situation. 

Appearing  simultaneously  with  the  exanthem,  or 
sometimes  even  earlier,  there  is  an  erythema  character- 
ised by  a  deep,  diffuse  redness  of  the  mucous  membranes 
of  the  mouth,  invading  the  pillars  of  the  soft  palate,  the 
uvula  and  the  tonsils  (Bue,  Petrovich).  From  the 
second  day,  on  the  mucous  membrane  of  the  palate,  a 
certain  number  of  red  spots  (5  to  15),  from  1  to  3  milli- 
metres in  diameter,  may  sometimes  be  observed.  They 
very  soon  disappear.     Their  outlines  are  denticulated. 

These  buccal  spots  invade  the  respiratory  passages. 
All  sufferers  present,  from  the  outset,  a  dry,  fitful 
cough,  which  later  on  is  accompanied  by  expectoration. 
This  is  often  very  profuse,  purulent,  and  fetid. 

The  appearance  of  the  eruption  coincides  with  an 
aggravation  of  the  intensity  of  all  the  morbid  symptoms. 
The  nervous  disorders  and  the  delirium  are  aggravated. 
The  eye  is  haggard,  the  face  now  pale,  now  flushed. 
The  temperature  oscillates  between  104°  and  106°  ;  the 
pulse  is  small  and  feeble  ;  the  number  of  beats,  in  cases 
of  average  severity,  being  from  110  to  120  per  minute. 
It  is  at  tliis  stage  that  sudden  impulses  toward  suicide 
are  observed,  and  extreme  agitation,  during  which 
the  patient  seeks  to  get  up  and  go  out ;  if  he  is  not 
watched  he  will  make  his  escape.     In  the  benign  forms 


SYMPTOMATOLOGY  457 

of  tlic  disease  tlie  nervous  system  is  not  greatly  affected 
by  the  toxins  ;  tlie  sick  physician  will  take  notes  of  his 
own  case  (Bue).  However,  in  addition  to  the  spinal 
pains  and  gastralgia  which  are  not  uncommon,  a 
cutaneous  hyperesthesia  may  be  observed,  local  or 
general,  and  sometimes  extremely  intense. 

Toward  the  eighth  day  it  seems  as  though  the  dis- 
ease were  about  to  reach  its  termination.  The  tem- 
perature falls  a  couple  of  degrees,  or  even  four  ;  but 
this  deceptive  remission  is  of  brief  duration  (twenty- 
four  hours  at  most).  The  fever  reappears,  as  severe  as 
before,  and  is  maintained  vmtil  the  fifteenth  day. 

During  this  second  portion  of  the  critical  period 
nervous  disorders  are  constant,  more  or  less  accentuated, 
and  varying  infinitely  in  the  case  of  different  patients. 
Certain  sufferers  exhibit  a  calm  and  gentle  delirium  ; 
plunged  in  a  semi-torpor,  they  mutter  incoherently. 
In  others  the  delirium  is  definitely  systematised,  re- 
volving round  a  fixed  idea. 

Lastly,  a  delirium  of  action  may  be  observed,  which 
is  influenced  by  terrifying  hallucinations.  It  is  very 
similar  to  that  of  delirium  tremens  (de  Brun),  and  is 
accompanied  by  a  return  of  the  suicidal  impulses. 

Convulsive  crises  have  also  been  observed  (R.  Job 
and  E.  Ballet). 

Generally  speaking,  the  delirium  is  not  of  long  dura- 
tion, although  in  certain  cases  it  has  been  known  to 
persist  even  after  defervescence  (de  Brun).  Often 
enough  it  disappears  after  two  or  three  days,  to  give 
rise  to  prostration  and  stupor.  About  the  ninth  day 
of  the  disease  the  patient  is  inert,  lying  in  the  dorsal 
decubitus,  the  eyes  almost  closed,  the  pupils  contracted, 
the  hearing  much  impaired.  The  patient  is  completely 
indifferent  to  all  that  is  happening  around  him  :  he 
does  not  recognise  those  about  him,  and  it  is  very 
difficult  to  rouse  him  from  his  torpor.  Sometimes  he 
is  plunged  into  a  sort  of  coma,  which  lasts  until 
defervescence  or  death. 

However  slight  it  may  be,  the  prostration  of  the 


458      DYSENTERY,  CHOLERA,  AND  TYPHUS 

typhus  patient  is  of  a  very  special  kind.  Remlinger 
has  recently  drawn  attention  to  one  of  its  peculiarities, 
which  he  has  called  the  "  sign  of  the  tongue."  The 
typhus  patient  cannot  protrude  his  tongue  from  his 
mouth,  or  can  do  so  only  at  the  cost  of  extreme 
effort.  Fimiey,  Godelier,  Billot,  Maurin,  Masse,  and 
H.  de  Brun  had  already  noted  this  fact,  and  also  that 
in  certain  cases  the  tongue  even  seemed  to  be  retracted 
toward  the  pharynx.  Some  writers,  moreover,  have 
noted  fibrillary  movements,  and  tremors  of  the  tongue, 
as  well  as  difficulty  in  speaking.  In  1893,  referring 
to  the  nervous  manifestations  which  he  had  observed 
during  the  Beyrout  epidemic,  H.  de  Brun  remarked: 
"  The  tongue  seems  as  if  fixed  to  the  floor  of  the 
mouth  ;  it  is  heavy  and  sticky,  and  is  moved  with 
difficulty  ;  speech  is  slow  and  often  tremulous.  .  .  . 
When  the  tongue  is  protruded  from  the  mouth  it  is 
animated  by  incessant  vermicular  movements  ;  it  is 
alwaj^'s  moving,  and  cannot  be  kept  motionless  in  one 
position  ;  the  commissures  of  the  lips  also  are  twitching, 
owing  to  the  trembling  of  the  levator  muscles,  and  the 
whole  jaw  may  jerk  so  violently  that  I  have  sometimes 
found  it  impossible  to  take  the  buccal  temperature.  In 
forms  of  medium  or  slight  intensity  the  speech  is  con- 
spicuously tremulous,  and  this  symptom  may  persist 
so  long  after  defervescence  that  it  has  enabled  me 
to  form  a  retrospective  diagnosis  six  weeks  after 
recovery." 

Congested,  broad,  and  more  voluminous  than  in  the 
normal  condition,  the  tongue  is  covered  with  a  mucous 
coating  which  is  at  first  white,  then  yellow,  then  brown 
or  black,  thick,  and  covered  with  cracks.  The  edges 
and  the  tip  are  a  bright  red.  At  other  times  it  is  small, 
dry,  and  withered,  as  though  baked  and  shrivelled. 
The  lips  and  teeth  are  dry,  black,  and  fuliginous. 

Tremors  are  not  localised  only  to  the  tongue,  lips, 
and  jaw;  they  may  also  be  observed  in  the  hands 
and  forearms,  the  oscillations  here  resembling  alcoholic 
tremor  (de  Brun). 


SYMPTOMATOLOGY  459 

Subsultus  tendinum  is  more  constant  and  more 
accentuated  than  in  typhoid  fever. 

The  cutaneous,  abdominal,  and  cremasteric  reflexes 
are  fairly  constantly  suspended  (Potel). 

The  abdomen  is  flat,  or  slightly  distended  ;  con- 
stipation is  persistent,  or  else  one  or  two  diarrhoeal 
stools  may  be  observed.  There  is  often  relaxation  of 
the  sphincters,  evacuation  and  urination  being  in- 
voluntary. Sometimes  also  there  is  an  actual  retention 
of  urine  which  necessitates  the  use  of  the  catheter. 

The  urine,  rather  more  abundant  than  at  the  outset, 
very  frequently  contains  albumin,  with  or  without  any 
increase  of  urea.  The  albuminuria  noted  in  50  per 
cent,  of  patients  usually  disappears  about  the  fifteenth 
day.  The  skin  is  hot,  sometimes  moist.  The  pulse 
rarely  exceeds  115  to  the  minute  ;  it  is  small,  feeble, 
compressible,  and  often  intermittent  (Netter).  The 
spleen  is  slightly  enlarged.  The  emaciation  is  extreme. 
The  vasor-motor  sign  of  supra-renal  insufficiency  is 
pretty  constantly  observed  (Bue).  Combemale  in  four 
cases  has  noted  a  development  on  the  face,  of  a 
greyish,  crystalline  efflorescence;  two  of  these  cases 
died  in  a  few  hours. 

4,  The  Period  of  Termination. — Death  occurs  in  15  to 
50  per  cent,  of  the  cases,  the  period  of  its  occurrence 
varying  ;  but  it  most  frequently  supervenes  during  the 
second  week,  on  the  eleventh,  twelfth,  or  thirteenth  day 
(Jeanneret-Minkine).  It  is  most  commonly  due  to  a 
sudden  cardiac  syncope. 

In  favourable  cases  a  critical  improvement  occurs 
on  the  fourteenth  or  fifteenth  day.  Very  rarely  defer- 
vescence is  sudden,  occurring  in  a  few  hours.  More 
commonly  the  temperature  falls  slowly,  defervescence 
assuming  the  form  of  lysis.  In  three,  four,  or  five  days 
it  becomes  normal,  or  even  subnormal.  At  the  same 
time  the  pulse  suddenly  falls  to  80,  and  is  sometimes 
even  abnormally  slow,  while  maintaining  the  normal 
qualities  of  rhythm  and  tension. 


460     DYSENTERY,  CHOLERA,  AND  TYPHUS 

The  skin  scales  off  in  fine,  small,  squamous  flakes, 
which,  as  they  approach  desquamation,  give  the  skin  a 
greyish-white,  metallic  lustre  (Escalier).  The  nervous 
symptoms  are  progressively  abated,  and  in  a  few  daj^s 
have  disappeared.  Sometimes,  after  a  peaceful  sleep, 
of  several  hours,  the  patient  awakes  transformed.  He 
recognises  those  about  him ;  he  is  no  longer  delirious,  but 
his  deafness  usually  remains  and  is  more  or  less  marked, 
while  the  haggard  expression  persists  for  some  weeks. 

The  tongue  grows  moist  and  clean ;  the  appetite 
returns  and  is  insatiable  ;  there  is  frequently  a  sudoral, 
polyuric,  or  diarrhoeal  crisis. 

Muscular  impotence  is  very  marked,  and  emacia- 
tion extreme.  The  convalescence  is  always  long,  the 
strength  returning  slowly,  and  the  patient  is  very 
quickly  fatigued.  For  about  a  month  the  convalescent 
experiences  a  sensation  of  physical  depression  and 
general  exhaustion,  an  exaggerated  need  of  food  and 
very  prolonged  sleep. 

Recurrence  is  rare,  but  possible. 

Complications 

The  complications  which  may  make  their  appearance 
during  convalescence  are  numerous. 

Among  these  we  must  give  the  first  place  to  myocar- 
ditis, which  is,  if  not  of  invariable  occurrence,  yet 
extremely  frequent,  and  is  betrayed  by  the  acceleration 
and  enfeeblement  of  the  cardiac  pulsations,  the  very 
marked  deadening  of  the  heart  sounds,  the  diminution 
of  arterial  pressure,  and  the  failure  and  irregularity  of 
the  pulse.  A  careful  examination  of  the  heart  should 
be  made  every  day,  in  order  to  provide  against  the 
sometimes  fatal  complications  which  accompany  cardiac 
insufficiency. 

Broncho-pidnionary  complications  are  also  frequent. 
Simple  bronchitis,  capillary  bronchitis,  pneumonia,  or 
broncho-pneumonia  may  be  encountered.  The  patient 
may  complain  neither  of  a  stitch  in  the  side,  nor  of 


SYMPTOMATOLOGY  461 

a  cough,  nor  of  expectoration ;  but  only  show  an 
acceleration  of  the  respiratory  movements,  with  a 
slightly  purplish,  cyanosed  coloration  of  the  face. 
Vomicce  have  been  recorded  (Combemale),  pulmonary 
gangrene,  and  purulent  pleurisy. 

Laryngo-typhus  may  be  observed,  as  well  as  ulcera- 
tions of  the  vocal  cords,  and  laryngeal  perichondritis  with 
oedema  of  the  glottis. 

Sacral,  trochanteric  and  malleolar  bed-sores  are  not 
uncommon. 

Ga7igrene  of  the  mouth,  the  scrotum,  the  labium 
majus,  the  extremities,  and  the  lower  limbs,  principally 
through  arterial  obliteration,  is  fairly  common  ;  it  may 
vary  considerably  in  extent,  sometimes  necessitating 
numerous  operations. 

Periostitis  and  peripheral  neuritis  (Job  and  Ballet, 
Bue)  are  also  observed  with  some  frequency,  as  are 
lymphatic  suppurations,  phlegmons,  adenitis,  and 
erysipelas  (Delearde  and  d'Halluin),  etc. 

Suppurative  otitis  media  and  suppurative  parotitis 
are  frequently  observed,  as  is  also  phlegmasia  alba 
dolens.  Certain  patients  suffer  from  a  considerable 
oedema  of  the  lower  limbs  long  after  recovery  from 
typhus,  and  this  sometimes  coincides  with  oedema  of 
the  eyelids,  most  frequently  without  albuminuria. 
Lastly,  Delearde  and  d'Halluin  and  Bue  have  noted 
the  exceptional  gravity  of  bucco-pharyngeal  diphtheria 
when  it  develops  during  the  developing  period  of 
typhus,  or  during  convalescence,  and  the  frequency  of 
various  tubercular  manifestations  which  may  sooner  or 
later  appear. 

Clinical  Forms 

A  certain  number  of  clinical  forms  of  typhus  have 
been  described,  which  are  differentiated  by  the  pre- 
dominance of  certain  S5nm.ptoms,  or  the  rapidity  with 
which  the  disease  develops.  We  shall  briefly  re- 
capitulate these  forms. 


463      DYSENTERY,  CHOLERA,  AND  TYPHUS 

Inflammatory  Typhus. — A  form  which  occurs  in 
young  and  vigorous  subjects,  and  persons  belonging  to 
the  wealthier  classes  ;  it  is  characterised  by  a  high 
temperature,  violent  headache,  and  acute  delirium, 
in  the  course  of  which  attempts  at  suicide  are  not 
uncommon. 

Ataxic  Typhus,  Adynamic  and  Ataxo  -  Adynamic 
Typhus. — These  forms  are  sufficiently  characterised  by 
the  symptoms  which  serve  to  indicate  them  ;  they  are 
usually  serious. 

Typhus  siderans  ( Jaccoud),  in  which  death  may  ensue 
in  two  or  three  days,  sometimes  in  a  few  hours.  This 
form  is  observed  in  alcoholics  (Baudens). 

A  slight  form  of  typhus,  of  very  brief  duration,  is  also 
described  by  Hildebrand  as  typhus  levissimus  ;  it  is  not 
accompanied  by  eruptions.  In  this  case  the  initial 
period  may  pass  unperceived  unless  it  was  known 
that  an  epidemic  of  typhus  existed.  It  is  generally 
sudden,  with  shivering,  headache,  vertigo,  lassitude, 
and  insomnia.  The  tongue  is  coated,  the  skin  hot, 
the  spleen  slightly  enlarged,  and  a  little  bronchitis 
may  be  present.  These  symptoms  increase  for  four  or 
five  days ;  then  the  disease  quickly  terminates.  The 
patient  breaks  into  profuse  sweats,  and  frequently 
exhibits  labial  herpes.  These  cases  have  been  described 
by  Netter  as  ephemeral  fever.  There  are  also  abortive 
forms,  with  violent  onset,  which  suddenly  abate  after 
three  or  four  days.  The  patient  frequently  suffers 
from  facial  herpes. 

Lastly,  Jacquot  has  described  a  series  of  symptoms  : 
malaise,  slight  fever,  loss  of  appetite,  nausea,  headache, 
and  intellectual  debility,  which  may  be  exhibited  for 
several  weeks  by  subjects  exposed  to  contagion,  but 
who,  apparently,  have  not  contracted  typhus.  Jacquot 
describes  this  condition  as  "  typhisation  in  small  doses.''"' 
Combemale  noted  similar  clinical  phenomena  during 
the  Lille  epidemic.  They  are  due  to  attenuated  forms 
of  the  infection. 


CHAPTER   XVI 


DIAGNOSIS 


At  the  beginning  of  an  epidemic,  or  when  isolated  cases 
of  typhus  are  occurring,  the  diagnosis  is  not  easy.  It  is 
always  uncertain  before  the  appearance  of  the  eruption 
(Murchison). 

The  sudden  onset,  the  high  temperature,  rising  to 
104°  or  105°,  the  rapid  pulse,  of  100  to  120  per  minute 
from  the  first  days  of  the  disease,  the  early  appearance 
of  the  nervous  symptoms  (on  the  second  or  third 
day),  the  presence  of  constipation  without  intestinal 
phenomena,  the  profuse  and  frequent  epistaxis,  the 
phenomena  of  congestion,  the  injection  of  the  con- 
junctivae, the  state  of  the  mucous  membranes,  and 
upper  air  passages,  and  the  almost  constant  vomiting 
are  assuredly  not  to  be  disdained  as  elements  of  diag- 
nosis. They  do  not,  however,  acquire  their  full 
validity  until  the  appearance  of  the  exanthem,  with  all 
its  characteristics  :  its  sudden  commencement  (on  the 
second  to  the  fifth  day),  its  petechial  character,  the 
abundance  and  the  general  distribution  (except  on  the 
face)  of  the  eruptive  elements,  and  the  successive  trans- 
formation of  these  elements,  which  persist  for  some 
length  of  time.  Lastly,  the  verification  of  the  exan- 
them, the  "  sign  of  the  tongue,"  the  nervous  pheno- 
mena, and,  above  all,  the  tremor  and  the  loss  of  memory 
are  very  diagnostic. 

The  physician,  in  pursuance  of  Netter's  advice,  may 
derive  great  assistance  from  the  following  factors  : 

1.  The  existence  of  transmitted  cases  among  the 
members  of  the  medical  staff  (physicians,  orderlies, 
nurses,  etc.). 

463 


464     DYSENTERY,  CHOLERA,  AND  TYPHUS 

2.  The  social  position  of  the  first  sufferers  (vagrants, 
destitute  persons,  prisoners,  etc.). 

3.  The  not  infrequently  advanced  age  of  the  patients. 

4.  The  predominance  of  the  disease  in  cold  weather. 
The  diagnosis  is  usually  facilitated  by  such  factors 

as  the  knowledge  that  an  epidemic  exists  ;  the  well- 
established  fact  that  the  patient  comes  from  a  house 
where  there  have  been  cases  of  typhus  ;  that  be  has 
been  in  direct  or  indirect  contact  with  persons  suffering 
from  typhus.  But  even  in  such  cases  as  this  it  is  neces- 
sary to  establish  a  precise  differential  diagnosis. 

Typhoid  fever  is,  of  all  diseases,  the  one  which  presents 
the  closest  clinical  analogies  to  typhus.  Here,  how- 
ever, the  commencement  is  usually  much  less  sudden  ; 
the  injection  of  the  conjunctivae,  so  peculiar  to  typhus, 
is  absent  in  typhoid  fever.  The  eruption  appears  later, 
and  is  less  abundant.  However,  the  rose-coloured  spots 
may  become  generalised,  may  attain  large  dimensions 
and,  especially  in  time  of  war,  may  be  purpuric  or 
haemorrhagic  in  character.  In  typhoid  fever  diarrhoea 
is  more  frequent  than  constipation  ;  in  typhus  the  con- 
verse is  true.  In  typhus  the  temperature -rises  to  104° 
or  105°  at  the  outset,  and  remains  at  that  level  for  five 
or  six  days,  without  any  notable  remission.  During 
the  present  war  the  general  signs  and  symptoms  of 
torpor  have  sometimes  been  so  marked  during  the  course 
of  typhoid  fever  and  paratyphoid  fever  that  one  might 
have  believed  them  cases  of  typhus.  In  such  cases  the 
sero-diagnosis  of  non- vaccinated  subjects,  or  the  culti- 
vation of  the  blood,  during  life,  and  of  the  bile,  after 
death,  make  it  possible  to  establish  a  diagnosis.  In 
Serbia,  during  the  present  war,  Petrovich  observed 
instances  in  which  typhus  made  its  appearance  in 
typhoid  wards.  On  the  second  day  the  patients 
exhibited  photophobia  and  turgescence  of  the  face, 
while  a  dark,  diffuse  redness,  with  roseate  spots,  covered 
the  throat ;  the  tongue  was  coated  and  was  red  at 
the  edges  and  the  tip.  On  washing  the  arms  and 
the  trunk   with   soap  it   was  possible  to   verify  the 


DIAGNOSIS  465 

commencement  of  the  exanthem.  The  heart  sounds 
were  already  weakened. 

Relapsing  fever  begins  in  a  much  more  sudden  and 
dramatic  manner  than  typhus  ;  there  is  violent  shiver- 
ing, nausea,  bilious  vomiting,  a  temperature  of  104°, 
106°,  or  even  107°,  and  more  from  the  outset ;  there  is 
enlargement  of  liver  and  spleen,  the  latter  being  painful 
upon  percussion.  These  phenomena  suddenly  dis- 
appear at  the  end  of  four,  five  or  six  days.  The  tem- 
perature falls  to  normal  and  the  patient  may  think  he 
has  recovered.  But  after  the  lapse  of  about  a  week  a 
fresh  attack  develops,  in  every  way  resembling  the  first. 
There  is  no  exanthem,  or  at  most  a  limited  roseola  may 
be  observed,  but  this  is  exceptional.  Moreover,  during 
the  whole  course  of  the  attack  an  examination  of  the 
blood  reveals  the  specific  spirochsete. 

Malarial  fever  of  the  continuous  type  is  not  usually 
observed  during. the  same  season  as  typhus  in  countries 
where  malaria  and  typhus  are  endemic.  Typhus  is 
more  common  in  the  winter  and  spring,  malarial  fever  in 
the  summer  and  autumn.  The  hypertrophy  and  the  con- 
sistency of  the  spleen,  the  absence  of  an  exanthem,  and 
stupor,  combined  with  the  knowledge  that  malaria  is 
prevalent,  and  finally,  the  examination  of  the  blood, 
and  the  discovery  of  the  malarial  parasite,  will  establish 
the  diagnosis,  and  the  efiicacy  of  treatment  by  quinine 
will  subsequently  confirm  this. 

The  eruption  of  typhus  has  caused  the  disease  to  be 
confused  with  r^easles,  especially  in  children.  The 
prodromic  period  of  measles  is  highly  characteristic, 
with  its  coryza,  its  epiphora,  and  its  sneezing.  The 
eruption,  which  appears  about  the  fourth  day,  involves 
the  face,  which  typhus  respects.  In  measles  the  tem- 
perature falls  as  soon  as  the  exanthem  appears  ;  the 
spleen  is  normal. 

Cerebrospinal  meningitis  has  also  been  confused  with 
typhus.  In  meningitis  there  is  photophobia,  and  a 
dread  of  noise,  while  in  the  typhus  patient  there  is 
usually  deafness,  and  the  senses  are  dulled.     The  face 


466     DYSENTERY,  CHOLERA,  AND  TYPHUS 

of  the  sufferer  from  meningitis  expresses  suffering  and 
anxiety  ;  that  of  the  typhus  patient  stupor  and  in- 
difference. In  meningitis  there  is  stiffness  of  the  nape 
of  the  neck,  and  Kernig's  sign  is  present  ;  there  is  no 
exanthem.i 

Influenza  may  give  rise  to  exanthemata  Uke  that 
of  scarlatina,  or  measles,  or  papular  eruptions  (Van 
Swieten,  Comby,  Perrenot),  with  redness  of  the  pharynx 
and  a  typhoid  aspect,  which  may  give  rise  to  confusion 
at  the  beginning  of  epidemics.  The  onset  of  influenza 
is  even  more  sudden  than  the  onset  of  the  sudden  form 
of  typhus.  The  temperature,  which  at  first  rises  to 
104°  or  106°,  remains  only  for  a  short  time  at  that  level. 
Sometimes  it  drops  suddenly,  after  two  or  three  days, 
and  does  not  again  rise ;  sometimes,  after  a  sudden 
and  very  marked  fall,  lasting  twelve  to  twenty-four 
hours,  it  rises  as  high  as  before  the  fall,  forming  a  de- 
pression in  the  thermal  curve  like  an  inverted  steeple 
(J.  Teissier's  "  V  of  influenza  ")  ;  sometimes  it  falls  by 
lysis.  Apart  from  the  behaviour  of  the  temperature, 
the  oculo-nasal  catarrh,  the  arthralgia,  the  neuralgic 
character  of  the  headache,  which  is  often  supra-orbital, 
and  the  frequent  perspirations,  will  enable  the  physician 
to  form  a  diagnosis. 

Apical  pneumonia  is  sometimes  accompanied  by 
typhoid-like  phenomena,  though,  for  several  days, 
despite  careful  examination,  it  may  be  impossible  to 
discover  local  indications.  The  commencement  is,  as  a 
rule,  easily  specified  ;  the  dyspnoea,  the  dryness  of  the 
tongue,  the  redness  of  the  cheek-bones,  the  presence  of 
herpetic  vesicles,  the  absence  of  petechise,  and,  lastly, 
the  examination  of  the  lungs,  will  assist  the  physician 
to  establish  his  diagnosis. 

The  spotted  fever  of  the  Rocky  Mountains  presents 
remarkable  points  of  resemblance  to  typhus  :  it  com- 
mences with  violent  shivering  ;  the  temperature  rises 
to  104°  or  106°  by  the  second  day,  and  between  the 

^  In  certain   cases  purpuric  spots   appear  in   cerebro-spinal   fever, 
whence  the  nam©  spotted  fever. — Ed. 


DIAGNOSIS  467 

second  and  fifth  days  an  eruption  appears,  exactly  like 
that  of  typhus  ;  rose-coloured  spots  which  become 
generalised  and  are  transformed  into  petechise,  but 
which  first  appear  on  the  wrists  and  ankles ;  not  until 
later  do  they  reach  the  thorax  and  the  abdomen. 
Moreover,  there  is  constipation,  enlargement  of  the 
spleen,  delirium,  a  sub-icteric  tinge  of  the  skin  and  the 
conjunctivae,  scanty  and  albuminous  urine  and  oedema. 
This  disease  prevails  more  particularly  in  spring  and 
summer.  Wilson  and  Chowning  claimed  that  it  was 
due  to  a  piroplasma,  which  was  rare  in  the  peripheral 
circulation,  but,  on  the  other  hand,  abundant  in  the 
visceral  circulation.  Their  discovery  has  not  been 
confirmed  by  the  researches  of  StileS  and  Ricketts.^ 
Quinine  in  large  doses  is  said  to  possess  a  curative 
action  in  Rocky  Mountain  spotted  fever  (Anderson). 

Finally,  it  must  be  remembered  that  there  are  cases 
in  which  diagnosis  is  rendered  extraordinarily  difficult 
by  the  association  and  overlapping  of  two  quite  differ- 
ent maladies,  these  giving  a  type  of  "  mixed  malady  " 
(Kelsch,  Remlinger),  which  does  not  in  any  way  re- 
semble either  of  them.  Among  these  mixed  maladies 
we  should  specially  mention  the  association  of  typhus 
with  recurrent  fever,  with  typhoid  fever,  with  dysentery, 
and  with  scurvy.  Exceptional  in  time  of  peace,  these 
morbid  associations  are  not  rare  in  time  of  war.  It  is 
important  to  be  forewarned  of  their  existence. 

^  It  is  now  generally  accepted  that  Rocky  Mountain  spotted  fever  is 
a  variety  of  typhus.     The  disease  is  spread  by  ticks. — Ed. 


CHAPTER  XVII 

TREATMENT 

A  PATIENT  definitely  attacked  by  typhus,  or  merely 
suspected  of  typhus,  should  immediately  be  isolated 
in  a  spacious,  well-ventilated  room.  Bodily  cleanliness 
should  be  scrupulously  attended  to.  Diet  should 
consist  of  liquids  :  milk,  beef -tea,  lemonade,  with  the 
addition  of  wine,  and  diuretic  beverages  in  abundance. 
Alcoholic  drinks  and  preparations  should  be  re- 
served for  patients  whose  hearts  are  weak.  The  very 
numerous  systems  of  treatment  which  have  been 
recommended  have  not  always  given  the  excellent 
results  which  were  expected  of  them.  Among  these 
we  may  refer  to  the  blood-letting  treatment  (Clutter- 
buck  and  Armstrong),  the  stimulant  treatment  (Alison, 
Graves  and  Stockes),  the  hydrotherapic  treatment 
(Currie),  the  quinine  treatment  (Dundas),  the  emetic 
treatment  (Rasori),  etc. 

The  best  treatment  is  the  symptomatic  one.  High 
temperatures  and  intense  cerebral  phenomena  are 
beneficially  influenced  by  lotions  (Petrovski),  and 
warm,  or,  better,  cold  baths. 

The  headache  which  is  so  troublesome  during  the  first 
few  days  may  be  combated  with  preparations  contain- 
ing opium,  with  aspirin,  or  with  cryogenin.  The  latter, 
according  to  Marini  (of  Aleppo),  has  the  further  advan- 
tage, in  cases  of  typhus,  of  lowering  the  temperature, 
regulating  the  pulse,  and  procuring  for  the  sufferer  a 
sort  of  euphoria. 

Constipation,  if  it  is  present,  should  be  treated  by 
emollient  or  slightly  purgative  enemas,  or  by  laxatives. 
No  attempt  is  to  be  made  to  establish  diarrhoea.     The 

468 


TREATMENT  469 

respiratory  organs,  the  heart,  and  the  urinary  secretion 
must  be  closely  watched,  and  complications  treated 
by  the  usual  means.  In  cases  of  cardiac  collapse  during 
typhus,  Jeanneret-Minkine  recommends  massive  in- 
jections of  ethero-camphorated  oil. 

Bouyges  claims  to  have  obtained  good  results  by 
intravenous  injections  of  electrargol  and  colloidal  gold. 
This  last  drug  excites  powerful  reactions,  and  must  not 
be  employed  when  there  is  myocarditis. 

Gaston  has  reported  good  results  from  intravenous 
injections  of  citrated  and  iodised  serum. 

Legrain  and  Raynaud  (Algiers)  have  treated  typhus 
patients  by  subcutaneous  injections  of  the  serum  of 
convalescents.  The  temperature  has  fallen  very 
quickly,  has  remained  low  for  thirty  to  thirty -five  hours, 
the  pulse  has  improved,  the  general  condition  has  been 
ameliorated,  and  the  patients  have  recovered. 

During  the  present  war  Escluse  and  Liber  have 
attempted  to  treat  typhus  by  means  of  intravenous 
injections  of  the  blood  of  convalescents,  coagulation 
being  retarded  by  citrate  of  sodium.  By  this  method 
they  claim  to  have  obtained  recoveries  in  cases  which 
were  despaired  of.  The  injections  should  be  made 
from  the  fourth  to  the  tenth  day  at  latest.  The  blood 
should  be  drawn  from  a  robust  convalescent  whose 
defervescence  dates  back  only  eight  or  ten  days. 
Thirty  c.c.  may  be  injected  with  impunity  during  the 
twenty-four  hours,  in  three  instalments.  The  recovery 
of  the  patient  may  depend  upon  perseverance  in  the 
treatment. 

Finally,  Charles  Nicolleand  Ludovic  Blaizot  have  been 
able  to  produce  a  condition  of  hyper-immunisation 
in  the  ass  and  the  horse,  by  administering  repeated 
inoculations  of  emulsions  of  the  spleen  or  supra-renal 
capsules  of  guinea-pigs  infected  with  typhus.  The 
serum  of  these  animals  is  said  to  possess  actual 
preventive  power,  and  an  undeniable  curative  power. 
Non-toxic  to  man,  it  has  been  administered  in  thirty- 
eight    cases,    and    thirty-seven    times    with    success. 


470     DYSENTERY,  CHOLERA,  AND  TYPHUS 

MM.    Nicolle    and    Blaizot    give    the    treatment    as 
follows  : — 

1.  There  is  much  to  be  gained  by  commencing  the 
serotherapeutic  treatment  at  the  very  commencement 
of  the  disease,  immediately  the  diagnosis  is  admitted, 
or  even  suspected  merely. 

2.  The  inoculations  should  be  repeated  daily  until 
defervescence,  or,  at  all  events,  until  a  real  and  pro- 
found improvement  of  the  general  condition  is  obtained, 
foreshadowing  an  imminent  convalescence. 

3.  The  proper  doses  of  the  serum  are  10  c.c.  to  20  c.c. 
daily,  administered  hypodermically. 

4.  The  serotherapeutic  treatment  should  be  com- 
pleted by  a  medical  treatment  designed  to  favour  the 
elimination  of  the  microbic  toxins  and  the  residues  of 
the  defensive  reaction  of  the  organism.  This  medical 
treatment  consists  of  abundant  diuretic  beverages, 
tepid  baths  (82°  to  90°),  stimulants,  and  cardiac  tonics  ; 
lastly,  in  serious  cases  in  which  the  intoxication  is  pro- 
found, it  may  be  needful  to  inject  500  to  800  granomes 
of  artificial  serum. 


PART  //.—EPIDEMIOLOGY   AND 
PROPHYLAXIS   OF   TYPHUS 

CHAPTER  XVIII 

MEDICAL   HISTORY   AND    GEOGRAPHY 

Typhus  is  probably  as  old  as  man  himself.  We  find 
descriptions  which  answer  to  this  disease  in  the  Hebrew 
scriptures  and  in  the  medical  works  of  the  Arabs. 
In  the  narrative  of  the  terrible  plague  which  ravaged 
Greece,  and  of  which  Thucydides  was  the  historian, 
one  recognises  typhus.  The  first  study  of  this  terrible 
malady  is  due  to  Frascator.  There  was  no  lack  of 
material  for  observation,  for  Italy  was  decimated  by 
typhus  between  1505  and  1530.  Lautrec's  army, 
infested  by  the  disease,  left  30,000  dead  before 
Naples. 

Since  then  there  has  not  been  a  single  war  unaccom- 
panied by  typhus.  Physicians  learned  to  distinguish 
typhus  (Pesticula),  or  Typhus  petechialis,  from  plague, 
which  was  then  common.  All  the  wars  of  the  sixteenth, 
seventeenth,  and  eighteenth  centuries  were,  with- 
out exception,  the  occasions  of  a  return  of  typhus. 
The  armies  of  Charles  V.,  before  Metz,  were  ravaged 
by  this  disease.  During  the  wars  of  tjie  Revolution 
it  was  constantly  active.  The  French,  besieging  the 
Austrians  before  Mantua  in  1806,  were  as  severely 
visited  as  the  latter,  and  carried  the  germ  back  to 
France  with  them.  At  the  same  period  14,000  deaths 
were  reported  in  Genoa.  In  France  Montpcllier, 
Marseilles,  Toulon  and  Grenoble  were  infested  by 
typhus. 

After    the    battles    of    Austcrlitz    and    Jena    the 

471 


472     DYSENTERY,  CHOLERA,  AND  TYPHUS 

ambulances  and  hospitals  were  encumbered  with  typhus 
patients.  The  German  prisoners  brought  the  sickness 
to  France.  During  the  retreat  from  Russia  the  un- 
happy French  troops,  exhausted  and  covered  with  rags, 
died  by  the  thousand  along  the  road-side  at  Wilna.  In 
the  latter  city,  where  30,000  men  had  taken  refuge, 
25,000  succumbed ;  8000  of  the  inhabitants  also 
perished  by  typhus,  the  poorer  inhabitants  being 
principally  affected.  In  Dantzig  36,000  Frenchmen 
were  besieged  ;  13,000  died  of  typhus.  There  were 
10,000  deaths  among  the  civil  population.  At  Torgau 
14,000  men  out  of  26,000  succumbed.  At  Mayence 
also  20,000  soldiers  died  of  typhus. 

These  frightful  hecatombs  amply  justify  the  name 
which  at  this  period  was  given  to  the  disease — "  army 
typhus,"  "  camp  typhus."  It  seems  probable  that 
typhoid,  which  presents  clinical  analogies  to  typhus, 
9,nd  which  is  the  peculiar  scourge  of  armies  in  the  field, 
has  shared  with  true  typhus  the  responsibility  for  these 
terrible  onslaughts. 

Although  typhus  has  not  again  broken  out  with 
such  terrible  violence,  it  has  not,  however,  entirely 
disappeared. 

After  1815  typhus  persisted  in  convict  establish- 
ments, hulks,  and  prisons,  and  also  amid  the  poor 
and  wretched  populations  of  certain  countries.  It  per- 
sisted in  the  East,  in  Russia,  Prussia,  Poland,  Silesia, 
and  Ireland.  Between  1846  and  1848,  according  to 
Murchison,  there  were  300,000  deaths  from  typhus  in 
Ireland.  The  Crimean  War  reawakened  it.  At  first 
a  few  cases  appeared  among  the  Russians  ;  then  it 
spread  rapidly;  12,000  cases  and  6000  deaths  were 
reported  to  have  occurred  in  their  ranks.  The  French 
Army  was  attacked  in  turn.  The  soldiers,  crowded 
together  in  dug-outs  and  the  trenches,  exhausted, 
subjected  to  super himian  exertions,  and  deprived  of 
the  most  elementary  hygienic  attention,  were  struck 
down  in  the  proportion  of  one  in  ten  (F.  Jacquot). 
More  than  17,000  succumbed.     On  their  return  the 


MEDICAL  HISTORY  AND  GEOGRAPHY  473 

armies  infected  the  populations  of  Marseilles,  Toulon, 
Porquerolles,  and  Avignon. 

It  is  said  that  there  were  a  few  cases  of  typhus  in 
the  French  Army  in  1870,  after  the  battle  of  Mans,  and 
at  Mayenne  (Morisset),  but  this  fact  is  not  satisfactorily 
proved. 

On  the  other  hand,  during  the  Balkan  War  the 
Army  of  the  Danube  had  82,451  cases  (54-8.  per  1000), 
and  10,031  deaths  (17-02  per  1000).  The  Army  of  the 
Caucasus  had  15,660  cases,  with  6506  deaths. 

The  disease  showed  a  few  cases  at  the  outset  of  the 
war,  then  spread  rapidly,  especially  when  the  cold 
weather  set  in  and  the  men  were  packed  together 
in  cattle-sheds. 

The  proportion  of  cases  in  the  Army  of  the  Caucasus 
was  as  follows  : —    ■ 


November,  1877 

.      4-69  per  1000 

December      ,,     . 

.     19-65   „      ,, 

January,  1878 
February    ,,         . 
March         ,,         • 

.  43-85  „  „ 
.  46-90  „  „ 
.     38-13  ,,      „ 

April          ,,         . 
May            >,         • 
June           jj         . 

.  22-65  „  „ 
.  12-38  ,,  „ 
.       6-08    .,      „ 

Erzeroum  and  Khorassan  were  the  centres  most 
severely  infected.  Certain  regiments  were  almost 
annihilated.  A  company  of  the  74th  Regiment,  on 
entering  Kara-Kilisse,  was  made  up  thus :  First  came 
a  lieutenant,  on  a  stretcher,  paralytic,  with  sores. 
Beside  him  came  his  sub-lieutenant.  These  two  officers, 
and  eight  men  carrying  the  stretchers,  represented  all 
that  was  left  of  the  company.  "  The  rest/'  said  Koslov 
laconically,  "were  in  the  hospitals  or  the  tomb." 

Typhus  was  again  encountered  by  the  belligerent 
armies  during  the  Balkan  Campaign  of  1912. 

There  was  no  outbreak  of  typhus  during  the 
Manchurian  War. 

During  the  present  war  against  Germany  no  ease  of 
typhus  has  so  far  been  observed  in  the  French  Army. 


474      DYSENTERY,  CHOLERA,  AND  TYPHUS 

Bacteriological  investigations  have  shown,  in  certain 
suspected  cases,  that  these  were  really  malignant 
and  hypertoxic  forms  of  typhoid  fever,  the  typhoid 
bacillus  being  isolated  from  the  blood,  or,  after  death, 
from  the  spleen  and  the  gall-bladder. 

The  civil  population  has  been  equally  free  from  it. 
The  disease  has,  however,  been  raging  in  the  German, 
Austrian,  and  Russian  armies,  and  among  the  in- 
habitants of  those  countries  as  well. 

In  the  prisoner's  camps  in  Germany,  as  a  result  of 
a  deplorable  hygiene  and  the  abandonment  of  the  sick, 
large  mmibers  of  cases  and  deaths  have  occurred  among 
soldiers  of  the  Allied  armies. 

In  Germany,  at  the  present  time,  a  hundred  cases  are 
reported  monthly  among  the  civil  population.  The 
German  Army  has  not  been  spared,  and  many  physicians 
also  have  succumbed  to  the  disease. 

During  the  first  year  of  the  war  there  were  in  Austria- 
Hungary,  according  to  Jeanneret-Minkine,  about  1500 
cases  of  typhus  monthly. 

Serbia,  during  the  present  war,  has  of  all  countries 
been  most  cruelly  scourged  by  typhus.  Soldiers  and 
inhabitants  have  succumbed  in  enormous  numbers. 
It  is  estimated  that  typhus  has  claimed  at  least  135,000 
victims,  and  160  physicians  have  perished  while 
attending  to  the  sick.  In  one  American  ambulance 
eleven  nurses  out  of  fourteen  were  attacked. 

The  origin  of  this  terrible  epidemic  was  due  to  the 
70,000  Austrian  prisoners  interned  in  Serbia,  who 
brought  the  disease  with  them.  It  spread  in  every 
direction,  and  almost  every  house  was  stricken.  It 
is  estimated  that  one  person  out  of  every  five  was 
attacked.  The  mortality  in  the  hospitals  was  19  to 
65  per  cent.  In  Belgrade  there  were  7000  cases  in  less 
than  six  months.  The  towns  of  Valjevo,  Nish,  Monastir, 
and  Uskub  were  most  seriously  affected. 

It  must  not,  therefore,  he  supposed  that  this  infectious 
disease  is  extinct  in  these  regions. 

Apart  from  war-time,  it  has  been  and  is  still  prevalent, 


MEDICAL  HISTORY  AND  GEOGRAPHY    i75 

although  by  no  means  frequent,  among  the  civil 
populations.  In  1868  the  natives  of  Algeria,  being  in 
a  state  of  famine,  had  to  be  collected  in  relief  stations, 
where  the  disease  was  not  slow  to  make  its  appear- 
ance. It  was  then  for  the  first  time  that  cases  of 
typhus  were  observed  among  Europeans  who  had  been 
in  contact  with  the  starving  Arabs,  who  were  them- 
selves, however,  exempt  from  typhus,  at  all  events 
in  appearance. 

A  few  sporadic  cases  are  fairly  often  reported  in 
Volhynia,  Austria,  and  Holland. 

Ireland  and  Norway  are  also  subject  to  outbreaks. 
In  Spain,  Castellvi  reported  that  he  had,  in  1909, 
observed  545  cases  of  typhus  in  Madrid.  It  Italy, 
in  1888,  an  epidemic  caused  2099  deaths. 

In  France,  in  1870-1871,  551  cases  and  121  deaths 
were  reported  at  Riant ec,  near  Lorient.  The  epidemic 
continued  for  fourteen  months. 

At  Rouisan  in  1877  there  were  165  cases  ;  in  the 
lies  Molenes  in  1878,  282  cases  and  12  deaths  ;  in  the 
lie  Tudy,  in  1891,  80  cases. 

In  1892-1893  scattered  cases  of  typhus  appeared, 
first  in  Amiens,  in  a  night  shelter  for  vagrants  and 
tramps,  then  in  Abbeville,  Pontoise,  Beauvais,  Evreux, 
Mayenne,  Saint-Denis,  Paris,  Dieppe,  Lille,  Havre,  and 
Bordeaux  (among  the  workers  of  the  port  and  in  the 
Nanterre  prison). 

In  all  684  cases  were  reported.  About  100  physicians, 
nuns,  and  assistants  were  infected  in  the  north  of 
France. 

Between  1903  and  1912  (inclusive)  there  were  209 
cases  of  typhus  in  France. 

In  Russia  a  serious  epidemic  was  reported  in  Petro- 
grad  during  the  winter  of  1864-1865  (causing  nearly 
12,000  deaths).  Between  1905  and  1911  there  were 
665,865  cases  and  54,533  deaths  from  typhus  (Pottevin). 

In  England,  between  1899  and  1913,  there  were  only 
390  deaths.  In  Ireland,  during  the  same  period,  there 
were  1043  deaths.     In  1914  there  were  37. 


476      DYSENTERY,  CHOLERA,  AND  TYPHUS 

In  Sweden,  since  the  epidemic  of  1875,  which  caused 
1918  cases,  typhus  has  become  much  less  frequent. 

In  Germany,  the  very  serious  epidemics  which 
occurred  among  the  French  armies  in  1813  appeared 
among  the  inhabitants  also  :  18,000  cases  and  3024 
deaths  were  recorded  in  Bavaria,  between  November, 
1813,  and  June,  1814.  In  the  kingdom  of  Prussia  alone 
the  epidemic  caused  200,000  deaths  in  1813. 

There  were  epidemics  in  Prussia  in  1867-1869,  and 
in  Berlin  ;  in  Koenigsberg  in  1880-1882  (672  cases  and 
97  deaths).  Silesia  remained  the  most  virulent  centre 
of  the  disease.  In  1868-1869  there  were  1333  cases  in 
that  province ;  in  1878-1879,  600  cases.  Between 
1877  and  1910,  14,655  persons  infected  with  typhus 
were  treated  in  the  German  hospitals  (Pottevin). 
Cases  were  reported  in   Silesia  (district  of  Oppeln)  in 

1912,  1913,  and  1914. 

Austria  and,  above  all,  Galicia  and  Poland  have  been 
particularly  infested  by  typhus.  Between  1904  and 
1913  (inclusive)  Galicia  was  responsible  for  24,107 
cases  of  typhus,  and  2282  deaths. 

The  Bukovina,  Bohemia,  and  Bosnia-Herzegovina 
are  not  exempt.  The  disease  reappeared  at  the 
commencement  of  the  war  of  1914,  among  the  Austrian 
troops  and  in  most  of  the  provinces.  The  Austrian 
prisoners,  as  has  been  stated,  carried  it  into  Serbia. 

In  Rumania  typhus  is  very  rare.  However,  during 
the  first  three  months  of  the  war  there  were  forty  cases 
in  Bukarest.  There  is  typhus  in  Bulgaria.  It  was 
prevalent  among  the  troops  during  the  war  of  1912- 

1913,  above  all  at   Chataldja  and  Adrianople,  and  at 
Philipopolis,  in  Macedonia,  in  July,  1914. 

In  1914,  fifty-one  cases  and  thirty-one  deaths  were 
recorded  at  Salonika.  Fresh  cases  made  their  appear- 
ance in  1915. 

Turkey,  in  which  country  there  is  a  lack  of  exact 
statistical  infonmation,  is  the  accustomed  home  of 
typhus  epidemics.  Cases  have  been  observed  in  Con- 
stantinople, Smyrna,  Trebizond,  Adalia,  Konieh,  and 


MEDICAL  HISTORY  AND  GEOGRAPHY     477 

Karpout,  and  at  Gallipoli,  in  1914-1915  both  in  the 
army  and  among  the  civil  population  of  the  country. 

In  Persia,  Ispahan,  Hamadan,  etc.,  were  visited  during 
the  year  1914  by  an  epidemic  of  typhus. 

In  the  north  of  Africa,  notably  in  Algeria,  Tunis  and 
Morocco,  typhus  prevails  in  a  mildly  sporadic  condition, 
with  occasional  epidemic  outbreaks,  in  the  native  douars. 
Its  propagation  is  facilitated  by  the  customs  of  the 
country  ;  the  sick  man,  supported  under  the  arms, 
walks  about  the  streets  to  combat  the  fever,  and  in 
the  midst  of  an  epidemic  typhus  patients  in  the  eruptive 
stage  have  been  seen  moving  about  the  streets  of 
Tlemcen  (Dauthuile).  The  Arabs  and  vagrants,  in 
return  for  a  trifling  payment,  sleep  packed  together 
in  the  Moorish  cafes  and  fondouks,  where  they  infect 
one  another. 

Cases  of  typhus  affecting  Europeans  have  been 
reported  from  Western  Morocco  also,  and  rigorous 
prophylactic  measures  had  to  be  taken  to  eradicate 
the  disease. 

Egypt  yearly  furnishes  a  large  number  of  cases.  In 
1914  there  were  9350  cases  and  2634  deaths.  During 
the  first  six  months  of  1915  there  were  14,505  cases  and 
3398  deaths.  The  disease  attacks  the  natives  more 
particularly. 

In  Central  America,  in  Mexico,  typhus  is  known  by 
the  name  of  labardillo.  Between  1904  and  1913  there 
were  56,719  cases  and  14,758  deaths. 

In  the  United  States  typhus  is  endemic  (Nathan 
Brill),  introduced,  or  maintained  by  immigrants. 


CHAPTER  XIX 

ETIOLOGY    OF    TYPHUS 

Predisposing  Causes 

Typhus  does  not  appear  to  spare  any  race  or  races. 
All  (Latin,  Slav,  Anglo-Saxon,  Indian,  Chinese,  etc.) 
pay  it  tribute.  The  Arabs  and  Turks,  however,  are  its 
chosen  victims. 

The  malady  is  more  benign  in  children  and  adoles- 
cents. Its  gravity  increases  considerably  after  the  age 
of  thirty  or  forty. 

The  mortality  in  children  is  5  per  cent.  ;  in  adults  it 
is  8  to  20  per  cent.,  and  often  more.  It  increases  with 
age. 

According  to  Murchison  the  mortality  per  100 
patients  is  : 

Over  30  years  .  .  .  .35  per  cent. 

„  40   „  .  .  .  .45   „ 

,,  50   ,,  .  .  .  .  53   J, 

„  60   ,,  .  .  .  .  67   ,, 

During  the  Russo-Turkish  War  the  mortality  among 
assistant  surgeons,  orderlies,  and  the  men  of  the  supply 
trains  was  at  its  maximum  between  twenty-five  to 
forty  years  of  age. 

The  two  sexes  are  not  attacked  with  equal  frequency, 
women  being  more  frequently  attacked  than  men 
(Rochard). 

Typhus  is  a  malady  of  cold  or  temperate  countries. 
It  is  most  frequently  observed  during  the  cold  season, 
as  was  seen  during  the  Russo-Turkish  War.  According 
to  Brill,  the  severe  form  is  prevalent  more  especially  in 
winter  ;    the  attenuated  form  in  simxmer.     In  Mexico 

478 


ETIOLOGY  OF  TYPHUS  479 

typhus  does  not  exist  in  cities  where  the  temperature  is 
high,  such  as  Vera-Cruz. 

At  the  time  of  the  Serbian  epidemic  the  disease  was 
checked  in  simmxer. 

Typhus  has  been  intensely  prevalent  in  Serbia  during 
the  present  war,  ftom  the  end  of  December,  1914,  to 
July,  1915.  The  first  cases  made  their  appearance  in 
September,  chiefly  among  the  patients  in  the  typhoid 
wards,  in  the  hospital  for  contagious  diseases  at  Valjevo. 
It  was  during  the  retreat  to  Albania,  however,  that  it 
attained  its  greatest  severity.  The  epidemic  was 
"  the  most  serious  that  Europe  has  ever  experienced  " 
(Petrovich).  In  March  there  was  no  longer  the  least 
little  hamlet  untouched  by  the  scourge.  The  mass  of 
favouring  causes  which  are  most  commonly  incriminated 
were  all  united  in  the  case  of  this  unhappy  people. 

Crowding  results  in  the  readier  propagation  of  the 
germ  and  its  agents  of  transmission.  This  explains 
why  typhus  spread  so  rapidly  through  the  prisoner's 
camps  in  Germany  during  the  present  war. 

Famine  and  physiological  want  have  always  been 
incriminated  as  the  adjuvants  of  typhus.  Hence  the 
name  of  "  famine  fever,"  "  famine  typhus,"  which 
the  old  physicians  gave  the  malady.  Still,  it  is  im- 
portant to  note  that  these  depressing  conditions  go 
hand  in  hand  with  the  lack  of  personal  hygiene  and 
the  hygiene  of  clothes,  individual  un cleanliness,  and 
infection  by  means  of  vermin,  which  play  such  an 
important  part. 

Anaemia,  fatigue,  privation,  and  cachexia,  moreover, 
give  the  clinical  development  of  typhus  a  special  and 
particularly  serious  character,  which  has  been  observed 
in  all  those  epidemics  which  have  been  associated 
with  famine.  Under  these  circumstances  the  bastard 
non-febrile  forms  are  equally  numerous,  and  because 
their  exact  nature  is  habitually  misunderstood  they 
contribute  to  maintain  the  frequency  of  epidemic 
cases. 

In  Algeria,  above  all,  in  the  region  contiguous  to 


480      DYSENTERY,  CHOLERA,  AND  TYPHUS 

Morocco,  typhus  maintains  itself  in  the  numerous 
encampments  in  which  the  natives  of  Morocco  live  in 
promiscuity,  without  hygienic  precautions.  A  serious 
epidemic  broke  out  in  the  province  of  Oran,  in  1906,  on 
the  occasion  of  the  important  construction  works  of 
the  railway  to  Lalla-Marnia. 

The  harvest  in  the  Algerian  Tel  had  attracted  also 
numbers  of  natives  from  Tafilalet  or  Marakeesh,  where 
the  disease  was  prevalent.  A  number  of  physicians  died. 
Driven  by  famine,  the  cachectic  natives  of  Morocco, 
arriving  in  great  numbers,  brought  the  malady  into  the 
workshops,  into  the  houses  of  the  railway  workers  and 
the  agricultural  labourers,  and  infected  the  beggars 
and  the  indigent  (Surgeon-Major  Duthuile). 

Whichever  races  or  countries  are  infected,  typhus 
furnishes  a  body  of  predisposing  causes  the  nature  of 
which  is  fairly  uniform.  It  persists  more  especially 
among  poor  and  uncleanly  populations.  When  it 
attacks  the  civilised  inhabitants  it  does  so,  in  a  way, 
accidentally.  It  dies  out  on  the  spot  instead  of  giving 
rise  to  a  true  epidemic  state. 

In  famine- stricken  countries,  on  the  other  hand,  and 
also  in  armies,  its  appearance  may  be  terribly  serious, 
on  account  of  its  progressive  extension. 

This  was  exemplified  in  the  case  of  the  prisoners 
interned  in  the  German  camps  in  1915.  Their 
nomishment  was  extremely  bad  in  quality,  extremely 
insufficient,  and  only  partially  assimilable.  As  a  result 
the  prisoners  fell  into  a  positive  state  of  inanition  (Davy 
and  Brown,  Leonetti).  They  received  a  bath  only  once 
a  month,  or  once  in  two  or  three  months,  and,  covered 
with  vermin,  were  packed  into  small,  insanitary  huts, 
which  provided  six  cubic  metres  of  air  per  head  ;  the 
atmosphere  was  fetid.  All  these  factors  predisposed 
them  to  infection  in  the  highest  degree. 

In  the  camp  at  Langensalza,  in  April,  1915,  nearly 
the  whole  of  the  1000  prisoners  contracted  typhus 
(Leonetti).  It  is  said  that  on  an  average  thirty-five 
men   died    daily.      They   were    ill-attended,    without 


ETIOLOGY  OF  TYPHUS  481 

medicines,  and  their  clothing  was  insufficiently  dis- 
infected. In  the  camp  at  Niederzweren  typhus  also 
made  serious  ravages.  It  was  only  when  the  epidemic 
attacked  the  civil  population  and  the  garrison  that 
precautions  were  finally  taken.  At  Erfurt  there  were 
600  cases  among  20,000  prisoners.  In  the  camp  at 
GustroAv  the  hygienic  conditions  were  equally  deplor- 
able. The  12,000  prisoners,  suffering  from  cold  and 
hunger,  were  crowded  together  on  mouldy  straw,  with 
a  single  blanket  apiece,  which  was  worn,  and  often 
torn. 


CHAPTER  XX 

ETIOLOGY    OF    HYFEJJS— continued 
Determining  Causes 

Many  bacteriological  researches  have  been  undertaken 
with  a  view  to  isolating  the  pathogenic  agent  of  typhus ; 
this,  however  5  is  still  unknown.  ^  Cultivation  of  the  blood 
on  the  usual  media  gives  negative  results.  Thoinot  and 
Calmette  have  described  a  flagellated  parasite  ;  Bruhl 
and  Dubief  a  diplococcus ;  Gottschlick  a  protozoon,  like 
an  endoglobular  piroplasma.  or  free  and  motile ;  Plotz 
a  special  bacillus,  etc. 

Ricketts  and  Wilder  have  reported  the  presence  in 
the  blood  of  certain  rare  bodies,  always  free,  which 
Gavino  and  Girard  have  recognised  under  the  aspect  of 
"  bacilliform  bodies,"  2fi  by  1-2/a  in  diameter,  exhibit- 
ing at  the  extremities  two  small  masses,  rounded,  like 
the  weights  of  dumb-bells  ;  the  significance  of  these 
is,  hpwever,  extremely  obscure,  and  their  etiological 
functions  have  not  yet  been  demonstrated. 

Proescher  stained  blood-smears  for  five  to  ten  hours 
with  carbonate  of  methylene  blue  (1  per  cent.),  and 
carbolic  acid  (1  per  cent.) ;  he  then  saw  very  fine 
diplococci  and  diplobacilli  from  0-2/x  to  0-3/a  in 
length,  enclosed  in  the  endothelial  cells  of  the  blood- 
vessels. 

There  is  reason  to  believe  that  the  virus  of  typhus 
belongs  to  the  group  of  invisible  or  filterable  viruses. 
The  ultramicroscope  reveals  nothing  in  the  patient's 
blood. 

^  Quite  recently  a  spirochsete  has  been  described  in  Japan  in  cases 
of  typhus,  but  this  requires  confirmation.— Ed. 

482 


ETIOLOGY  OF  TYPHUS  483 

The  inoculation  of  typhus  blood  gives  rise  to  the 
malady.  Motshovkovsky,  after  five  fruitless  experi- 
ments upon  himself,  obtained  a  positive  result  the  sixth 
time.  Blood  was  drawn  from  a  young  girl  suffering  from 
typhus,  and  on  the  tenth  day  presenting  numerous 
petechise.  Motshovkovsky  was  inoculated  with  this 
blood.  The  incubation  period  lasted  eighteen  days, 
after  which  time  he  was  attacked  by  violent  shivering, 
fever  (104-9°),  delirium,  and  a  comatose  state  which 
lasted  for  fourteen  days,  accompanied  by  a  petechial 
eruption,  bronchitis,  and  myocarditis. 

In  Mexico,  where  typhus  is  frequently  prevalent,  and 
is  knoAvn  as  fabardillo,  Otero  inoculated  four  healthy 
individuals  with  the  blood  of  typhus  patients.  In  one 
case  the  injection  of  0-2  c.c.  of  blood  from  a  tahardillo 
patient  into  a  man  whose  physiological  condition  was 
poor  determined  a  serious  form  of  typhus  after  eleven 
days'  incubation. 

Yersin  and  Vassal,  in  Indo-China,  succeeded  in  in- 
oculating two  coolies  with  typhus,  by  means  of  blood 
drawn  on  the  second  day  of  the  malady.  The  incuba- 
tion period  lasted  fourteen  days  in  one  case,  twenty-one 
in  the  other. 

From  these  experiments  Ave  may  therefore  conclude 
that  the  parasite  of  typhus  exists  in  the  blood  of  the 
patient. 

Exact  confirmation  of  this  statement  has  been 
obtained  by  the  admirable  investigations  of  Ch.  Nicolle, 
Comte  and  Conseil,  of  Tunis. 

These  experts  have  established  the  fact  that  the 
higher  apes  are  receptive  to  the  typhus  Vii-us,  and  form 
the  most  favourable  subjects  for  inoculation.  They 
inoculated  a  chimpanzee  with  the  blood  of  a  typhus 
patient  on  the  third  day  ;  after  the  lapse  of  twenty-four 
hours  the  ape  was  suffering  from  fever,  and  on  the  fifth 
day  the  eruption  appeared  on  the  face,  ears,  and  flanks. 

This  was  not  a  case  of  a  lesion  of  a  toxic  order,  for  the 
blood  of  this  ape  was  itself  virulent  and  inoculable  on 
the  fourth  day,  when  it  was  injected  into  a  Chinese 


484        DYSENTERY,  CHOLERA,  AND  TYPHUS 

macacque,  which  developed  typhus  after  an  incubation 
period  of  thirteen  days.  It  was  not  inoculable  before 
the  fourth  day. 

To  sum  up,  the  injection  of  a  cubic  centimetre  of  the 
blood  of  a  typhus  patient  suffices  to  cause  the  certain 
development  of  typhus  in  the  chimpanzee.  The 
symptoms  and  the  development  of  the  disease  recall  in- 
fantile typhus  ;  the  fundamental  characteristic  is  fever. 
Death  may  result. 

In  this  way  innumerable  transfers  may  be  realised. 
After  recovery  the  apes  are  immune.  The  serum  of  a 
man  or  an  ape  possesses,  after  recovery,  preventive 
and  curative  properties  as  regards  the  ape,  but  does  not 
retain  them  for  more  than  fifteen  to  twenty-five  days. 

The  blood  is  virulent  two  days  beiore  the  fever  com- 
mences, and  while  the  fever  lasts,  and  for  a  few  days 
longer  (Nicolle,  Comte,  and  Conseil).  A  temperature 
of  55°  C.  applied  for  fifteen  minutes  (Gavino  and  Girard), 
or  even  of  50°  C.  (Nicolle)  kills  the  virus.  The  incuba- 
tion period  of  typhus  in  apes  is  from  four  to  twenty-eight 
days  ;  it  averages  froni  five  to  eight  days.  The  typhus 
of  apes  resembles  that  of  man  (injection  of  the  con- 
junctivae, exanthemata,  fever,  commencing  suddenly  or 
progressive,  anorexia,  prostration,  etc.). 

In  Mexico,  Goldberger  and  Anderson,  and  then 
Ricketts  and  Wilder,  shortly  after  Ch.  Nicolle  and  his 
collaborators  had  completed  the  above  experiments, 
confirmed  the  inoculability  of  the  typhus  virus  in  the 
Macacus  rhesus,  the  incubation  period  being  five  to 
twelve  days.  The  animals  recovered.  The  initial 
inoculation  was  almost  always  positive  in  its  results. 
Ricketts  and  Wilder  employed  the  serum  derived  from 
defibrinated  blood  subjected  to  centrifugalisation 
(Nicolle  allowed  the  blood  to  coagulate). 

Gavino  and  Girard  successfully  repeated  the  whole 
of  the  investigations  described  above  upon  Atelles 
vellerosifs. 

Diluting  the  blood  of  patients  and  filtering  it  through 
a  Berkefeld  filter,  Ricketts  and  Wilder  were  unable  to 


ETIOLOGY  OF  TYPHUS  485 

provoke  the  disease  by  inoculation  ;  but  the  portion  left 
upon  the  filter  was  virulent. 

Nicolle  succeeded  in  provoking  the  disease  by  the 
injection  of  filtered  blood  once  out  of  six  times. 
Campbell  failed. 

The  usual  "  laboratory  animals  "  have  usually  been 
regarded  as  refractory  to  typhus,  but  Nicolle  has 
demonstrated  that  the  guinea-pig  is  sensitive  to  the 
virus.  The  infection  is  revealed  by  one  symptom  only, 
and  that  an  inconstant  one — fever,  which  lasts  eight 
to  twelve  days,  commencing  a  week  after  inoculation. 
During  this  period  the  blood  is  virulent  if  injected  into 
the  monkey  or  the  guinea-pig,  even  if  the  animal  pro- 
viding the  blood  is  not  suffering  from  fever.  Transfers 
through  alternate  monkeys  and  guinea-pigs  can  be 
effected  indefinitely. 

On  separating  the  various  elements  of  the  blood, 
Nicolle  found  that  the  white  corpuscles  are  extremely 
virulent  in  infinitesimal  doses  ;  the  plasma  is  less  so  ; 
the  red  corpuscles  are  inactive. 

The  typhus  virus  appears,  therefore,  to  he  localised  in 
the  leucocytes  of  the  bloodA 

The  foregoing  discoveries  already  throw  an  interest- 
ing light  on  the  etiology  of  typhus.  We  are  forced 
to  ask  ourselves  what,  considering  the  contagiousness 
of  typhus^  is  the  medium  of  contagion  in  the  patient. 
Is  contagion  effected  by  the  normal  or  pathological 
secretions,  by  the  saliva,  the  expectorations,  the  urine, 
etc.  ?  It  does  not  seem  that  this  is  the  case,  contrary 
to  the  opinion  which  was  formerly  current.  Netter 
and  Nicolle,  in  this  connection,  deny  that  the  expec- 
torations play  any  part. 

On  the  other  hand,  the  plainly  demonstrated  exist- 
ence of  the  parasite  in  the  blood  would  lead  us  to 
suppose   that   the    transmission    of   the    vkus,  as   in 

^  The  blood  of  typhus  patients  and  of  the  animals  inoculated  reveals 
necrosis  of  the  polynuclear  neutrophiles,  sometimes  to  a  considerable 
extent.  The  nucleus  has'  a  mulberry-like  appearance,  and  the  proto- 
plasm shows  granulations  of  a  lilac  colour  (Nicolle). 


486       DYSENTERY,  CHOLERA,  AND  TYPHUS 

malaria  and  yellow  fever,  is  effected  by  an  ectoparasite 
or  by  the  bites  of  insects. 

Nicolle  has  found  that  the  bite  of  the  mosquito,  the 
tick,  the  stomoxys,  the  louse,  the  flea  or  the  bug,  after 
the  insect  has  sucked  the  blood  of  typhus  patients, 
is  without  effect  upon  the  normal  monkey. 

In  the  phosphate  mines  of  Tunisia,  where  the  fleas 
are  very  abundant  and  bite  everybody,  only  the 
natives  suffer  from  typhus. 

Mosquitoes  and  ticks  do  not  exist  in  winter,  nor  in 
spring,  seasons  at  which  typhus  is  especially  prevalent. 
Lastly  in  the  prisoner's  camps  in  Germany  where 
typhus  was  prevalent,  there  were  swarms  of  lice,  but 
no  fleas  or  bugs. 

Ricketts  and  Wilder  have  also  found  that  neither 
fleas  nor  bugs  can  transmit  typhus  to  the  monkey. 
Nicolle,  Conseil  and  Comte  have  proved  that  it  is  the 
louse,  and  particularly  Pediculus  vestimenti  which  serves 
as  the  agent  of  inoculation.  In  more  than  800  cases 
of  typhus  observed  in  Tunis  in  1908,  if  of  the  patients 
suffered  from  parasites,  or  were  vagrants  exposed  to 
the  bites  of  lice.  Their  contagiousness  disappeared 
when  they  had  been  bathed  and  given  a  change  of  linen. 
In  four  cases  of  typhus  the  malady  had  assuredly 
followed  the  bites  of  lice. 

Experimentation  has,  for  that  matter,  verified  the 
truth  of  this  proposition.  Lice  nourished  on  the 
blood  of  a  monkey  (Chinese  bonnet  monkey),  and 
left  v/ithout  food  for  eight  hours,  when  transferred 
to  another  monkey  (a  macacque)  infected  it  with 
typhus. 

Ricketts  and  Wilder  (the  first  of  these  scientists 
dying  of  typhus  on  the  occasion  of  these  experiments) 
also  obtained  positive  infections  with  body-lice  which 
had  been  placed  on  typhus  patients,  or  infected  apes, 
or  monkeys,  and  were  then  transferred  to  healthy 
animals.  The  same  effect  was  produced  by  taking  the 
excrement  of  lice  and  inoculating  it  under  the  skin,  or 
by  crushing  the  lice  themselves  and  inoculating  them. 


ETIOLOGY  OF  TYPHUS  487 

the  lice  having  sucked  the  blood  of  a  typhus  patient 
three  days  earlier.  Having  collected  a  thousand  young 
lice,  the  offspring  of  140  adult  lice,  fed  on  the  blood 
of  a  typhus  patient,  Ricketts  and  Wilder  reared  them 
to  the  adult  state.  This  generation  produced  lice 
which,  placed  upon  a  macaque,  caused  no  infection. 
But  afterwards  this  monkey  was  refractory  to  a  very 
powerful  inoculation. 

According  to  Nicolle  the  bite  of  the  louse  is  pathogenic 
only  from  the  fourth  to  the  seventh  day  after  an 
infective  meal. 

Pediculus  vestimenti  is  thus  the  intermediate  host,  as 
well  as  the  agent  of  transmission  of  typhus.  When  the 
louse  has  absorbed  the  blood  of  a  typhus  patient  the 
parasite  of  typhus  infects  the  louse  itself  after  the  lapse  of 
a  few  days.  Possibly  this  infection  causes  an  actual 
disease  in  the  louse.  At  all  events,  a  multiplication  of 
the  typhus  germ  takes  place,  and  after  a  period  of  a  few 
days  the  germ  has  become  inoculable  into  man.  Perhaps 
it  is  in  the  louse  itself  that  we  might  most  fruitfully  search 
for  the  virus. 

It  may  be  concluded,  then,  that  the  agent  of  trans- 
mission for  the  virus  is  the  body-louse,  after  the  insect 
has  fed  upon  a  person  affected  by  the  disease.  The 
blood  of  the  patient  is  virulent  during  the  whole  course 
of  the  malady,  and  even  for  some  days  before  the  onset, 
and  a  few  days  after  recovery. 

The  infectious  germ  survives,  maintaining  its  viru- 
lence, in  the  alimentary  canal  of  the  louse,  multiplies 
there,  and  undergoes  a  special  development ;  it  is 
inoculated  by  the  louse,  or  by  its  very  profuse  excrement 
deposited  on  a  cutaneous  excoriation.  Experiments 
upon  monkeys  have  verified  this  latter  mode  of 
contagion. 

The  louse  is  capable  of  transmitting  tjrphus  for  a 
few  days  only.  But  it  may  once  more  become  con- 
tagious after  a  fresh  infective  meal.  Finally,  its 
offspring  may  sometimes  transmit  the  infection 
(Nicolle). 


488     DYSENTERY,  CHOLERA,  AND  TYPHUS 

Examples  cited  by  Jeanneret-Minkine  show  that  the 
bite  of  the  louse  may  be  much  more  certainly  infective 
than  involuntary  inoculation  with  instruments  polluted 
by  the  blood  of  the  typhus  patient.  This  was  exempli- 
fied by  an  attendant  in  a  post-mortem  room,  who  re- 
mained unaffected  in  spite  of  excoriations  and  daily 
wounds  which  he  did  not  disinfect.  However,  this 
man  contracted  typhus  later,  while  attending  on  a 
patient. 

Cases  have  been  cited  in  which  typhus  seems  to  have 
developed  independently  of  the  bites  of  Pediculus 
vestimenii.  Physicians  attending  typhus  patients,  but 
protected  by  rubber  gloves  and  hennetic  overalls  and 
boots,  have  nevertheless  contracted  typhus.  This  fact, 
if  verified,  would  seem  to  prove  that  the  louse  is  not 
the  only  agent  of  transmission  (Larrieu).  Still,  it 
appears  to  be  demonstrated  that  one  single  bite  of  an 
infected  louse  is  capable  of  provoking  typhus.  It  is  easy 
to  understand  that  this  bite  might  pass  unnoticed, 
especially  as  the  louse  bites  almost  immediately,  if 
hungry. 

Of  the  three  species,  P.  capitis,  P.  pubis,  and 
P.  vestimenii,  the  latter  is  by  far  the  most  usual  agent 
of  transmission.  P.  capitis,  having  bitten  a  typhus 
patient,  retains  the  virus  for  at  least  twenty  hours, 
and  if  placed  upon  a  monkey  gives  it  typhus  (Anderson 
and  Goldberger).  P.  vestimenii,  in  the  adult  state, 
attains  a  length  of  3  and  even  4  millimetres  (Jeanneret- 
Minkine).  It  has  three  pairs  of  limbs,  by  means  of 
which  it  fixes  itself  upon  clothing  or  moves  about.  It 
lodges  in  the  folds  and  seams  of  clothing,  or  upon  the 
surface  itself.  It  lays  its  eggs  on  the  fibres  of  cotton 
or  woollen  garments,  but  it  can  also  deposit  them  on 
the  hairs  of  the  body.  From  its  birtli,  which  takes 
place  in  six  or  seven  days,  the  insect  bites  the  human 
host.  The  eggs  may  also  be  laid  on  tlie  covers  of 
mattresses.  The  best  temperature  for  "liatching  is 
82*4°  F.  It  is  retarded  by  temperatures  of  76° 
or  95°  to  104°. 


ETIOLOGY  OF  TYPHUS  489 

P.  vestimenti  lives  only  upon  blood, and  dies  if  deprived 
of  it  for  two  to  five  days.  It  does  not  settle  on  the  skin 
except  while  puncturing  it  for  the  purpose  of  obtaining 
nourishment.  Extremely  avid  of  blood,  it  absorbs 
excessive  quantities  of  it,  even  as  much  as  a  milli- 
gramme. This  explains  the  abundance  of  its  dejecta, 
by  means  of  which  infection  may  occur  if  the  victim 
scratches  himself. 

The  capacity  of  multiplication  possessed  by  P. 
vestimenti  is,  according  to  Jeanneret-Minkine,  consider- 
able, for  in  one  month  a  couple  may  give  birth  to  more 
than  2000  descendants.  Moreover,  among  the  Arabs 
one  sometimes  sees  persons  whose  bodies  and  garments 
are  entirely  covered  with  these  parasites. 

When  it  is  hungry  the  louse  is  capable  of  deserting 
abandoned  garments  or  straw  bedding  and  of  going 
in  search  of  its  food.  It  can  therefore  make  its  way, 
although  slowly,  toward  an  adjacent  human  being. 
This  is  certainly  what  takes  place  in  cantonments 
and  trenches,  where  men  who  are  not  infested  may 
be  contaminated  by  sleeping  on  straw. 

The  body-louse  does  not  survive  in  hot  climates. 
This  has  been  observed  in  Mexico.  At  Tampico  the 
louse-infested  labourers  who  come  in  search  of  work 
are  rid  of  their  lice  in  five  days,  although  no  measures 
have  been  taken  to  destroy  them.  The  serious  epidemic 
which  was  lately  raging  in  Serbia  was  arrested  in  spring 
"  because  at  this  season  the  lice  had  disappeared  " 
(Hirschfeld). 

Numerous  examples,  recorded  by  the  medical  history 
of  typhus,  testify  to  the  excessive  contagiousness  of  the 
disease. 

The  introduction  of  the  germ  by  a  single  patient  may 
give  rise  to  a  serious  epidemic.  This  was  seen  on  the 
occasion  of  the  epidemic  of  1893.  Thoinot  and  Ribierre 
have  summarised  the  p^rt  played  by  contagion  in 
respect  of  the  cases  which  occurred  in  Paris  at  this 
time  in  an  instructive  table. 


490     DYSENTERY,  CHOLERA,  AND  TYPHUS 

Twenty  vagrants  suffering  from  typhus  (in  Paris) 

infected  : 

At  the  poorhouse       In  asylums,  police-stations,    At  the  Palais 
and  lodging-houses  de  Justice 

41  persons  under  de-     42  vagrants,  3  lodging-house       1  recorder 
tention,  4  warders  keepers,  3  other  persons 


These  typhus  patients,  nursed  in  the  hospitals,  caused  23  cases. 

A  total  of  137  persons  infected. 

Typhus,  as  we  have  seen,  is  transmissible  during  the 
prodromal  period.  In  1893,  at  Lille,  fifteen  persons 
who  had  come  into  contact  with  a  prisoner  contracted 
typhus.  Now  the  prisoner  himself  did  not  develop 
typhus  until  several  days  later.  Typhus  is  also  trans- 
missible after  recovery.     At  the  same  period  a  female 

patient,  Mme   F ,  of  Amiens,   carefully   isolated, 

having  recovered  from  a  benign  form  of  typhus,  left 
hospital  and  communicated  the  disease  to  another 
woman  who  called  to  see  her.  A  few  days  later  she 
went  to  Dreux,  and  introduced  the  disease  there. 

The  facts  already  expounded  as  to  the  function  of 
the  Pediculus  give  us  the  explanation  of  the  delayed 
transmission  of  the  disease  by  lice  which  have  drawn 
blood  at  the  end  of  the  febrile  period,  or  even  several 
days  later,  when  the  blood  was  still  infective.  The 
louse  itself  retains  the  germ  of  typhus  for  several  days, 
and  this  after  a  definite  period  of  incubation. 

It  will  therefore  be  understood  how  typhus  may  be 
propagated  not  only  by  those  who  have  been  in  direct 
contact  with  the  patient,  but  also  by  those  who  have 
come  into  contact  with  his  clothes,  his  body-linen,  his 
bedding,  his  mattresses,  his  straw  bedding,  etc. 

It  should,  however,  be  remembered  that  P.  vestimenti 
dies  after  the  lapse  of  a  few  days  if  unable  to  nourish 
itself  upon  blood. 

The  propagation  of  typhus  has  been  reported  in  the 
case  of  orderlies  who  have  handled  the  clothing  of  typhus 
patients,  those  who  have  charge  of  the  cloak-yoom  in 
hospitals,  and  those  who  repair  soldiers'  overcoats  if 


ETIOLOGY  OF  TYPHUS  491 

these  have  not  been  disinfected.  Contagion  may  also 
be  effected  in  railway  carriages,  public  vehicles,  prisons, 
etc.,  through  the  medium  of  lice  in  search  of  a  human 
host.  However,  the  cause  of  infection  may  remain 
uncertain.  This  was  the  case  with  an  advocate  who 
contracted  typhus  in  1895,  at  Lille,  in  the  Palais  de 
Justice,  where  vagrants  and  thieves  were  tried.  He 
died,  as  did  his  secretary.  It  was  impossible  to  discover 
the  source  of  contagion.  ^ 

The  older  generation  of  physicians  laid  great  stress 
on  the  transmission  of  typhus  by  famishing  masses  of 
persons  who  themselves  were  apparently  unaffected 
(Perier,  Vital,  Maurin).  Kelsch  has  confirmed  this 
hypothesis.  The  episode  of  the  Shea-Gehald,  cited  by 
Griesinger,  is  well  known.  This  vessel  sailed  from 
Egypt  in  November,  1860,  arriving  at  Liverpool  on  the 
16th  February  following.  She  carried  a  native  crew, 
ill-fed,  suffering  from  diarrhoea  and  sea-sickness,  but 
with  no  case  of  typhus  among  them.  Now  three  persons 
who  visited  the  vessel  on  her  arrival  contracted  typhus  ; 
one  of  them  died.  Some  sailors  sent  to  the  hospitals  on 
account  of  various  affections  carried  typhus  thither  : 
1  physician,  1  student,  2  male  nurses,  2  porters  and 
17  patients  were  attacked.  The  sailors,  to  the  number 
of  340,  visited  the  baths  ;  3  bath-house  attendants  out 
of  6  contracted  typhus,  etc. 

It  seems  highly  probable  that  there  was  typhus 
among  these  men,  but  that  it  existed  in  some  ill-defined 
form  such  as  is  frequently  observed  among  famine- 
stricken  or  ill -nourished  persons.  Moreover,  eleven 
deaths  had  occurred  during  the  voyage  through  the 
Mediterranean. 

These  unusual  forms  of  typhus,  without  fever,  but 
with  diarrhoea,  loss  of  strength,  and  early  or  sudden 
death,  have  been  observed  during  all  epidemics,  and 
in  particular  during  the   Serbian  epidemic  of   1915. 

^  Why  not  the  louse  ?  Vagrants  and  thieves  are  notoriously  lousy, 
and  it  seems  highly  probable  that  the  advocate  and  the  secretary  were 
bitten  by  infected  lice  introduced  by  these  people. — Ed. 


492     DYSENTERY,,  CHOLERA,  AND  TYPHUS 

Numbers  of  these  cases  were  variously  diagnosed  as 
physiological  want,  dysentery,  etc. 

The  epidemiological  importance  of  these  bastard 
forms  need  not  be  emphasised.  A  precise  inquiry 
should  always  be  made  in  order  to  trace  the  antecedents 
of  such  cases.  As  we  have  seen,  this  is  not  always  easy 
to  establish.  It  often  happens  that  the  first  cases  are 
unrecognised.  At  other  times  patients  or  convalescents 
are  sent  into  neighbouring  hospitals,  and  are  discharged 
too  early,  and  without  disinfection.  These  patients 
spread  typhus  wherever  they  go  by  means  of  the  lice 
which  they  carry  with  them. 


CHAPTER  XXI 

PROPHYLAXIS    OF    TYPHUS 

Although  typhus  has  not  hitherto  been  observed  in 
the  French  and  British  armies,  and  although  the  civil 
population  has  been  free  from  it,  we  may  consider  that 
this  infectious  disease,  which  is  prevalent  in  the  armies 
of  the  east  and  south-east  of  Europe,  is  always  a  inenace 
to  our  armies,  because  of  the  conditions  of  life  to  which 
the  men  in  the  trenches  and  cantonments  at  the  front 
are  subjected,  the  multiplicit}?^  of  human  contacts,  and 
the  profusion  of  ectoparasites  which  afflict  our  soldiers. 
It  is  therefore  important  thoroughly  to  under^stand  the 
prophylactic  measures  to  be  opposed  to  this  disease. 

The  campaign  against  lice  remains  the  most  profitable 
means  of  prophylaxis,  and  that  which  should  be  most 
urgently  insisted  upon.  This  point  will  be  specially 
dealt  with  later. 

Wherever  the  disease  has  manifested  itself  an  early 
notification  should  be  made  of  every  case.  The  patient 
should  be  strictly  isolated  in  a  special  ward,  in  a  port- 
able building  in  winter,  or  in  a  tent  in  summer. 

Immediately  upon  admittance  the  hair  of  the  head 
should  be  cropped,  the  hair  of  the  body  shaved,  and  both 
should  be  burned.  The  patient  should  be  placed  in  a 
bath  containing  corrosive  sublimate,  washed,  soaped, 
and  scrubbed,  and  all  his  parasites  destroyed.  His 
clothes  should  be  burned  or  sent  to  the  oven  directly 
upon  his  admittance  to  hospital.  If  this  is  not  done 
they  should  be  plunged  immediately  into  boiling  water 
containing  washing-soda. 

All  persons  who  have  been  in  contact  with  the  patient, 
and,  above  all,  those  who  are  infested  with  lice,  should 
be  placed  under  supervision  for  a  period  of  fifteen  days. 

493 


494     DYSENTERY,  CHOLERA,  AND  TYPHUS 

This  precaution,  therefore,  applies  to  families,  ships' 
crews,  or  passengers,  military  units,  workshops,  Arab 
douars,  prisons,  etc.  All  suspects  should  undergo  a 
scrupulous  insect  disinfection,  by  means  of  antiseptic 
baths,  soaping,  etc.  The  hair  and  beard  should  be 
cropped  or  shaved,  while  clothing,  underclothing,  boots 
or  shoes,  caps,  etc.,  are  to  be  sterilised  or  destroyed  by 
fire. 

,  The  quarters  inhabited  by  the  patient,  his  linen, 
sheets,  mattresses,  bedding,  etc.,  must  be  subjected  to 
disinfection  ;  the  linen  and  articles  to  be  sent  to  the 
stove  should  be  placed  in  special  sacks  ;  the  infected 
premises  should  be  disinfected  with  sulphur  gas ; 
articles  of  no  value,  such  as  rubbish,  worn  clothing, 
mats,  carpets,  etc.,  should  be  destroyed  by  fire  ;  the 
floor  should  be  washed  with  a  boiling  solution  of  soda 
(1  per  cent.).  The  persons  entrusted  with  the  work  of 
disinfection  must  wear  special  clothing  and  rubber 
gloves. 

On  board  ship  the  same  precautions  should  be  taken, 
while  passengers  and  crew  .are  to  be  subjected  to 
sanitary  supervision  for  fifteen  days.  Carriers  of 
vermin  must  be  placed  under  observation  for  the  same 

period. 

In  hospitals  the  nurses  or  orderlies  should  be  selected 
from  the  younger  members  of  the  staff ;  those  who 
have  already  had  typhus  should  be  chosen,  if  such  are 
available.  They  should  wear  special  clothing  :  blouses 
closing  tightly  at  the  neck  and  wrists,  rubber  gloves, 
trousers  fitting  closely  at  the  ankles,  with  well-laced 
boots,  and  a  head-covering  or  "helmet"  of  linen.  In 
the  British  hospitals  in  Serbia  the  staff  wore  a  single 
garment,  a  sort  of  "  combination,"  closed  at  the  neck, 
buttoning  at  the  shoulders,  with  the  ends  of  the  trousers 
shaped  to  enclose  the  feet ;  the  latter  were  shod  with 
sandals.  Nurses  or  orderlies  must  not  relax  their 
precautions,  experience  having  frequently  shown  that 
after  some  time  they  are  apt  to  become  forgetful,  and 
so  contract  the  disease. 


PROPHYLAXIS  OF  TYPHUS  495 

Blouses,  aprons,  head-coverings,  etc.,  should  be  re- 
moved by  the  attendants  when  they  leave  the  ward  or 
go  to  meals.  A  change  of  clothing  is  advisable  each 
time  a  fresh  patient  is  admitted. 

Instructions  as  to  the  means  by  which  typhus  is 
transmitted,  and  the  part  played  by  lice  in  the  spread 
of  contagion,  should  be  issued,  and  everyone  should  be 
reminded  of  the  difficulty  of  protecting  themselves 
against  the  bite  of  the  louse,  and  of  all  the  precautions 
to  be  taken  to  avoid  them,  particularly  on  the  arrival  of 
patients  who  have  not  as  yet  been  disinfected.  Nurses, 
doctors,  and  attendants  should  take  an  antiseptic  bath 
daily  (containing  cresol  or  corrosive  sublimate). 

No  specific  prophylaxis  has  so  far  been  discovered. 

Anderson,  however,  has  suggested  that  persons 
exposed  to  typhus  would  act  prudently  by  getting 
themselves  inoculated  with  attenuated  typhus  (Brill's 
disease). 

Nicolle  attempted  to  immunise  twenty  Serbian 
soldiers  and  eighteen  other  persons  by  injecting  half  a 
cubic  centimetre  of  serimi  from  an  infected  guinea-pig, 
followed,  at  an  interval  of  nine  days,  by  one  cubic  centi- 
metre. He  obtained  satisfactory  results,  which  should 
encourage  others  to  repeat  such  experiments. 

The  Campaign  against  Lice 

The  transmission  of  typhus  by  the  pediculi  necessi- 
tates, as  its  prophylactic  consequence,  the  "  disinsecti- 
fication "  or  "  disinsectisation "  of  the  patient,  his 
entourage,  and  all  those  who  approach  him  or  have 
approached  him. 

Pediculus  vestimenti  lives  more  particularly  in  or  on 
the  surface  of  clothing.  The  frequency  of  vermin 
among  soldiers  in  the  field,  even  among  those  who 
take  precautions  as  to  cleanliness,^  would  constitute  a 

^  According  to  Peacock,  4 '9  per  cent,  of  the  British  soldiers  have  no 
lice  ;  41  -9  per  cent,  have  very  few.  The  rest  suffer  from  them  in 
varying  degrees. 


496     DYSENTERY,  CHOLERA,  AND  TYPHUS 

formidable  factor  of  propagation  were  the  virus  to  be 
imported.  It  is  important,  therefore,  to  describe  the 
various  means  designed  to  destroy  these  parasites. 

1.  For  the  individual  himself  numerous  means  have 
been  recommended :  swabbing  with  petrol,  xylol, 
benzine,  essence  of  aniseed,  turpentine,  ether,  chloro- 
form, essence  of  cloves,  or  of  eucalyptus,  etc.  These 
volatile  liquids,  it  is  to  be  remembered,  are  inflammable ; 
nevertheless,  they  are  really  efficacious,  especially 
xylol ;  the  nits  often  resist  benzine. 

Frictions  with  anisol  (methyl-phenyl-ether)  may  be 
recommended.  A  mixture  of  oil  and  petrol,  less 
volatile,  is  equally  useful.     The  mixture  ; 

pulverised  on  the  skin  (and  clothing)  with  an  ordinary 
pulveriser  effectually  destroys  lice.  This  means  is 
recommended  in  the  Italian  Army  by  Guido  Izar. 

Sachets  for  personal  wear,  containing  naphthaline 
and  camphor,  placed  under  the  armpits  or  at  the  waist, 
are  of  little  use.  Sulphur  has  no  effect,  and  the  same  is 
true  of  powdered  pyrethrum. 

The  British  Army  makes  considerable  use  of  the 
N.C.I,  powder,  composed  as  follows  : — 

Naphthaline         .  .  .  .96  grammes 

Creosote  .  .  .  .  .      2        ,, 

Iodoform .  .  .  .  .      2        ,, 

This  powder  is  applied  to  the  skin,  shirts,  trousers, 
etc.,  and  renewed  every  five  days.  It  does  not  kill 
eggs  with  certainty. 

Swellengrebel  has  recommended  anisol,  globol  (para- 
dichloro-benzene),  which  is  non-toxic,  or  lausofane, 
a  cyclo-hexanon  base  and  cyclo-hexanon  associated, 
in  powder  or  alcoholic  solution,  with  which  the  skin 
is  soaked  or  covered  while  the  clothing  is  being 
disinfected. 

The  hair  of  the  head  and  body  should  be  cropped  or 
shaved,  and  the  body  should  be  soaped  with  soft  soap 


PROPHYLAXIS  OF  TYPHUS  497 

or  cresol  soap  ;  this  treatment  should  be  continued  for 
a  fortnight.  Brumpt  recommends  washing  with  three 
parts  of -soft  soap  mixed  with  one  part  of  glycerine. 

The  nits  of  P.  pubis  are  destroyed  by  a  solution  of 
corrosive  sublimate  (1  in  1000),  to  which  30  per  cent,  of 
acetic  acid  has  been  added  (Brumpt). 

Excellent  results  are  also  obtained  by  swabbing  the 
pubic  and  axillary  regions  with  strong  alcohol,  in  which 
10  per  cent,  of  /?.  naphthol  has  been  dissolved. 

All  these  local  operations  should  be  followed  by  a 
bath. 

After  each  bath,  disinfected  clothing  should  be 
•donned.  The  process  of  insect  disinfection  must  be 
carefully  carried  out,  for  an  imperfectly  cleansed 
person  may  in  a  few  days  reinfect  all  his  neighbours. 

The  hair  of  the  head  should  be  cropped  very  close, 
and  soaked  in  a  mixture  of  oil  and  petrol. 

2.  The  de,struction  of  lice  on  clothing  is  effected  by 
means  of  heat,  dry  or  moist,  or  by  anti-parasitical 
vapours. 

Lice  are  killed  in  three  hours  by  a  temperature  of 
45°  C.  (113°  F.) ;  in  one  and  a  half  hours  by  a  temperature 
of  50°  C.  (122°  F.) ;  in  twenty  or  thirty  minutes  by  a  tem- 
perature of  60°  C.  (140°  F.) ;  and  in  ten  minutes  by  a 
temperature  of  80°  C.  (176°  F.). 

The  nits  are  more  resistant. 

Dry  heat  applied  by  a  hot  iron  effectually  kills  lice 
and  eggs  on  clothing,  but  the  iron  must  be  carefully 
passed  several  times  along  all  the  seams. 

Boiling  destroys  the  parasites.  Ordinary  coppers 
or  lye-washing  machines  of  80  litres  capacity  are 
employed,  and  give  excellent  results  (Voyotte). 

Live  lice,  placed  in  test-tubes  in  the  midst  of  clothing, 
are  killed  by  this  process  in  three  or  four  minutes  ;  in 
ten  minutes  the  embryos  in  the  nits  are  killed  (Brumpt). 

A  note  issued  by  the  General  Staff,  Direction  de 
Varriere^  dated  the  28th  August  1916,  suggests,  as 
an    emergency  method   of   disinfecting   clothing,   the 

^  As  distinguished  from  the  medical  service  in  the  field. 


498    DYSENTERY,  CHOLERA,  AND  TYPHUS 

employment  of  a  barrel  (as  recommended  by  Surgeon- 
General  Richard)  placed  above  a  saucepan  or  copper 
which  is  giving  off  steam.  The  bottom  of  the  barrel  is 
perforated  to  allow  the  steam  to  pass  through. 

The  same  note  recommends  the  emplojnnent  of 
Budan's  device,  which  consists  of  two  coppers  or  vats, 
of  unequal  size,  one  being  placed  over  the  other.  The 
whole  is  heated  by  means  of  wood  or  coal. 

Finally,  a  supply  of  steam  may  be  employed  .(from  a 
boiler  or  agricultural  engine),  the  exhaust-pipe  ending 
in  a  barrel  containing  the  articles  to  be  disinfected. 

The  Bordas  process  consists  in  passing  steam  through 
a  worm  contained  in  an  ordinary  barrel. 

It  is  as  well  to  use  alkaline  water  in  the  coppers  in 
order  to  increase  its  bactericidal  power. 

In  Amsterdam  the  destruction  of  lice  is  effected  by 
the  vaporisation  of  ammonia  (25  per  cent.)  in  hermetic- 
ally closed  rooms. 

In  the  German  Army  sulphuret  of  carbon  is  regarded 
as  being  possessed  of  great  activity. 

The  employment  of  silken  underclothing  has  been 
recommended  in  place  of  woollen  or  cotton  articles,  as 
the  lice  cannot  effect  a  lodgment  on  silk. 

When  the  articles  have  been  sufficiently  baked  or 
steamed,  they  should  be  carefully  dried  before  being 
worn  again. 

During  the  operation  of  disinfecting  and  drying  the 
clothing  and  underclothing  the  carrier  of  the  vermin 
himself  may  be  shaved,  disinfected,  soaped,  and  bathed. 

Thanks  to  these  measures,  typhus,  which  has  made 
such  serious  ravages  in  Serbia,  has  been  stamped  out. 

Rumania  succeeded  in  protecting  herself  against  the 
importation  of  typhus  from  Serbia,  by  means  of  adopt- 
ing the  same  measures  on  the  frontier,  and  by  imposing 
a  rigorous  quarantine  on  immigrants. 

It  was  the  same  with  Greece.  Travellers  coming 
from  contaminated  countries  received  an  inspection 
card,  containing  five  divisions,  on  which  the  tempera- 
ture  was   entered   for   five   days.     The  traveller  was 


PROPHYLAXIS  OF  TYPHUS  499 

required  to  visit  the  physician  under  penalty  of  a  heavy 
fine.  Useful  as  it  is,  this  measure  is  not  infallible,  for 
the  incubation  period  of  typhus  may  be  much  longer, 
and  in  infected  subjects  who  are  in  a  low  physiological 
condition  typhus  may  be  apyretic. 

The  treatment  of  clothing  by  the  vapour  obtained 
by  burning  sulphur  or  sulphuret  of  carbon  (CS2,  90 
percent.  ;  stove  alcohol,  5  per  cent.  ;  water,  5  per  cent.) 
destroys  the  parasites  very  effectively.  The  clothes 
are  hung  up  in  a  carefully  closed  room  or  closet. 

The  vapour  of  formol  is  less  reliable. 

3.  The  disinfection  of  rooms,  etc.,  can  also  be  effected 
by  the  use  of  sulphurous  acid  (50  grammes  per  cubic 
metre),  the  vapour  being  applied  for  two  or  three  hours. 

The  flooring  may  conceal  lice  derived  from  typhus 
patients,  underclothing,  healthy  subjects,  etc.  In  this 
case  it  is  best  to  go  over  the  planks  and  skirtings  with 
petrol,  or  to  wash  them  with  alkaline  boiling  water. 

The  staff  entrusted  with  the  insect  disinfection  of  lousy 
persons  and  their  clothing  must  take  all  necessary  pre- 
cautions to  avoid  infection.  They  should  wear  special 
garments,  frequently  changed,  and  rubber  gloves  to 
handle  the  infested  clothing.  The  latter  may  be 
collected  by  means  of  long  tongs  of  wood  or  metal  for 
transference  to  the  stove  or  oven. 

These  precautions  are  particularly,  reconmiended 
during  epidemics. 


SECTION  III 

SYPHILIS  AND 
THE  ARMY 


SYPHILIS  AND  THE 
ARMY 

CHAPTER    I 

THE  FREQUENCY  OF  SYPHILIS  IN  THE  ARMY 

All  great  movements  of  population — wars,  pilgrim- 
ages, exhibitions — ^induce  a  recrudescence  of  con- 
tagious diseases  in  general.  Venereal  diseases  in 
particular  always  become  more  frequent  in  time  of 
war. 

During  the  wars  of  the  Revolution  *  venereal  mor- 
bidity was  estimated  at  a  fourth  of  that  of  the  entire 
army. 

The  present  war,  owing  to  the  immensity  of  the 
armies  engaged,  its  long  duration,  and  the  large  num- 
bers of  men  mobilised  in  munition  works,  seems  hkely 
to  leave  all  previous  wars  far  behind,  as  regards  the 
frequency  of  venereal  diseases. 

Up  to  the  present  the  statistics  of  the  belligerent 
forces  are  unknown  t ;    and,  in  any  case,  they  could 

*  See  Spick,  "  Scabies  and  Venereal  Diseases  in  the  Armies  of 
the  "Revolution  and  of  the  Empire"  {Annates  de  dermatologit, 
October,  1908,  p.  593). 

t  Balzer  ("  Prophylaxis  and  Treatment  of  Venereal  Diseases  in 
Time  of  War,"  Presse  medicale,  October  14,  1915,  p.  40)  reports 
that,  according  to  German  statistics  going  to  the  end  of  February 
1915,  the  German  troops  at  this  period,  in  Belgian  territory  alone, 
had  already  had  30,000  cases  of  venereal  diseafse,  whereas  in  the 
war  of  1870-71  the  total  number  of  venereal  cases  had  been  32,528, 
viz.  70 '6  per  1,000  of  the  sick  in  hospital. 

503 


504  SYPHILIS  AND   THE   ARMY 

give  but  a  feeble  conception  of  this  frequency,  for  they 
are  most  incomplete,  for  several  reasons  : 

In  the  first  place,  medical  inspection  of  men  with 
the  colours  is  not  carried  out  with  sufficient  rigour 
to  obtain  accurate  figures,  for  divers  reasons. 

And,  on  the  other  hand,  it  is  not  only  amongst  the 
fighting  units  that  venereal  diseases  are  to  be  found  ; 
they  occur  also  amongst  convalescent  soldiers,  as  well 
as  amongst  munition  workers,  who,  from  the  health 
point  of  view,  must  be  regarded  as  soldiers. 

Consequently,  syphilis  is  frequently  seen  in  the  base 
hospitals,  without  precise  statistics  being  procurable  : 
many  of  these  centres  do  not  report  the  venereal  cases 
treated,  others  ignore  them.  Patients  suffering  from 
gonorrhoea  or  syphilis  gladly  take  advantage  of  their 
leave  to  obtain  treatment  unknown  to  the  doctor  in 
charge,  and  often  go  to  quacks. 

As  regards  munition  works,  despite  the  most  laud- 
able  efforts,  medical  supervision  is  most  inadequate. 
As  the  result  of  various  unfortunate  influences,  in 
the  majority  of  cases,  even  a  brief  medical  visit  is  not 
made, and,  there  is  no  doubt,  a  large  number  of  venereal 
patients  conceal  their  malady,  and  are  either  badly 
treated  or  not  at  all,  to  their  own  disadvantage  and  to 
the  still  greater  detriment  of  society  in  general. 

As  far  as  I  have  been  able  to  judge,  from  personal 
experience  and  from  conversations  with  numerous 
military  surgeons,  as  well  as  those  attached  to  the 
dermato-venereological  military  staff,  the  frequency 
of  gonorrhoea  has  been  markedly  increased  since  the 
war,  especially  in  certain  regions.  Mauriac  has  shown 
that  simple  chancre  has  a  tendency  to  Increase  at  a 
time  of  any  great  shifting  of  population,  but  its  occur- 
rence does  not  appear  to  be  above  the  average. 

As  regards  syphilis,  with  which  I  am  alone  con- 
cerned here, in  the  opinion  of  every  one,  it  has  increased 
notably  since  the  beginning  of  the  war,  and  there 
appears  to  be  almost  constant  augmentation. 


FREQUENCY  OF  SYPHILIS  IN  THE  ABMYmb 

As  I  have  already  stated,  statistics  give  but  a  very 
incomplete  idea  of  this,  because  they  only  comprise 
the  cases  observed  in  the  miUtary  hospitals,  and  many 
escape  notice  ;  further,  in  order  to  appreciate  this 
augmented  frequency,  it  would  be  necessary  to  obtain 
statistics  made  before  the  war  in  the  same  communi- 
ties. But  pre-war  communities  have  been  modified,  or 
rather,  one  might  say,  turned  upside  down  by  mobilisa- 
tion ;  army  corps  in  time  of  peace  in  no  way  resemble 
our  regiments  at  the  front,  as  regards  composition, 
and  there  was  nothing  comparable  to  munition  works 
in  the  industrial  works  of  1913. 

The  opinions  of  syphilologists  are  much  more  valu- 
able than  statistics.  The  unanimous  opinion  is  that 
the  frequency  of  syphilis  is  much  greater  at  the  present 
time  than  during  the  periods  preceding  the  war  :  all 
my  colleagues  in  Paris  and  the  provinces,  when  con- 
sulted on  this  subject,  agreed  as  to  this. 

I  shall  now  merely  give  some  statistics  : 

Gaucher,*  out  of  2,457  soldiers  treated  at  his  clinic 
from  August  1914  to  December  1915,  for  cutaneous 
or  venereal  affections,  recorded  277  cases  of  recent 
syphihs,  and,  amongst  88  soldiers  in  the  out-patient 
department,  24  cases  of  recent  syphihs. 

In  the  same  clinic,  from  January  1st  to  July  31st, 
1914,  out  of  a  total  of  2,295  patients,  he  observed 
276  chancres  or  recent  syphihs — in  round  figures  300 
cases  of  recent  syphilis  amongst  3,000  patients ;  and 
from  August  14th,  1914,  to  JJecember  31st,  1915,  in 
thie  same  cUnic,  4,912  patients,  both  civil  and  military, 
amongst  them  being  793  cases  of  recent  syphilis — say 
800  out  of  5,000  patients. 

*  Gaucher,  "  Venereal  Diseases  dvuing  the  War  in  the  Villemin 
Hospital  and  in  its  Annexes"  {Bulletin  de  VAcademie  de  Medecine, 
March  28th,  191f>,  p.  352). 

Gaucher  and  Bizard,  "  Statistics  of  Syphilis  contracted  by  Soldiers 
since  Mobilisation  and  treated  in  the  Clinic  of  the  Hospital  St.  Louis, 
August  1914 — December  1915  "  {Annalea  dee  maladies  veneriennes, 
March  1916,  p.  129). 


506  SYPHILIS  AND   THE  ARMY 

If  these  two  statistics  given  are  translated  into 
centesimal  proportions,  out  of  the  total  of  cutaneous 
and  venereal  patients,  they  represent  12%  of  venereal 
patients  before  the  war  and  16%  since  the  war,  there- 
fore an  increase  of  4%  or  of  |,  which  is  certainly  less 
than  the  reality  and  does  not  convey  an  exact  idea. 

In  a  cHnic  of  cutaneous  and  venereal  diseases  in  a 
colonial  army  corps,  out  of  a  possible  effective  force 
of  60,000  men,  Rousseau  *  treated  27  cases  of  syphi- 
litic chancre,  from  March  12th  to  July  1st,  1916, 
which  corresponds  to  89  cases  of  contamination  in  a 
year,  and  there  is  reason  to  believe  that  he  did  not  see 
all  the  cases. 

The  statistical  material  of  venereal  diseases  in  the 
French  Army  has  only  been  collected  since  the  year 
1916,  and  for  variable  periods  for  the  three  venereal 
diseases.  The  adjoining  table,  compiled  from  informa- 
tion given  me  by  the  kind  permission  of  Mr.  Justin 
Godart,  Under-Secretary  of  State  Health  Service  to  the 
Minister  of  War,  gives  the  number  of  contaminations 
reported  month  by  month  by  the  medical  men  of  the 
various  sanitary  departments. 

As  regards  syphilis,  this  table  shows  the  oscillations 
which  occur  in  the  frequency  of  the  disease,  and  of 
the  results  of  the  prophylactic  measures  prescribed  : 
but  it  does  not  by  any  means  comprise  all  the  syphihtic 
contaminations  which  occur  in  a  military  population, 
for  several  reasons.  Despite  the  orders  given,  a  con- 
siderable number  of  hospitals  do  not  furnish  detailed 
reports  ;  while,  on  the  other  hand,  large  numbers  of 
syphilitic  chancres  are  unrecognised,  as  the  result  of 
the  insufficiency  of  the  medical  visits  paid  to  the  regi- 
ments and  depots  ;  others  are  treated  unknown  to  the 
regimental  doctors.  Further,  these  statistics  only 
include  patients  who  were  admitted  to  hospital  for  a 
syphilitic  chancre  and,  in  order  to  prevent  errors  and 

*  Rousseau, "  Treatment  and  Prophylaxis  of  Syphilis  in  an  Army 
Corps"  [Presse  medicale,  October  23rcl,  1916). 


FREQUENCY  OF  SYPHILIS  IN  THE  ARMY507 

double  entry,  no  record  has  been  made  of  those  patients 
who,  on  admission,  showed  secondary  affections,  their 
chancre  having  been  unperceived,  or  unrecognised  for 
one  cause  or  another.  Therefore,  under  the  heading  of 
simple  chancre,  a  large  number  of  mixed  chancres  are 
hidden,  the  syphiUtic  phase  of  which  has  escaped  the 
statistics. 

Finally,    these    statistics    only   include    the    troops 

Venereai.  Contaminations  believed  in  the  Akmy  Troops  and  on 

THE  Land. 


Gonorrhoea. 

Simple 
Chancre. 

Syphilis. 

Total  of  venereal 
contaminations. 

^,i 

-C.2 

J3.2 

-§&■ 

si 

^S 

<^    M 

<i 

+3    U 

4i    U 

■^  ti 

-»    In   . 

5-5 

^1 

"5 

M 

E^ 

M   C 

o 

H 

1,460 

^< 

O 

January,  1916 







250 

1,210 

February    ,, 

1,018 

3,416 

4,434 





— 

321 

1,206 

1,527 

March         ,, 

641 

3,257 

3,898 





— 

170 

843 

1,013 

April            ., 

553 

2,434 

2,987 

71 

331 

402 

192 

660 

852 

816 

3,421 

4,241 

May 

337 

3,210 

3,547 

54 

457 

511 

161 

753 

914 

552 

4,420 

4,972 

June            „ 

569 

3,000 

3,569 

82 

428 

510 

169 

787 

956 

820 

4,215 

5,035 

July 

475 

3,068 

3,543 

64 

459 

523 

189 

794 

983 

728 

4,321 

5,049 

August 

414 

3,578 

3,992 

18 

417 

435 

131 

998 

1,129 

563 

5,124 

5,687 

Note. — For  the  months  of  January  and  February,  the  number  of  cases  of 
syphilis  in  the  Army  includes  not  only  patients  in  hospital  with  syphilitic 
3hancre,  but  also  those  suffering  from  secondary  affections ;  in  the  interior 
since  the  Army  started,  note  has  only  been  made  of  those  patients  in  hospital 
Evith  syphilitic  chancre. 


present  with  the  colours  ;  no  account  is  taken  of  the 
men  mobiUsed  in  munition  works.  Up  to  the  present 
there  is,  unforttinately,  no  record  of  the  cases  of 
syphiUs  among  them  ;  and  these,  from  personal  obser- 
vations and  the  confirmation  of  numerous  doctors, 
appear  to  be  of  enormous  frequency. 

For  all  these  reasons,  interesting  as  are  the  statistics 
of  venereal  diseases  among  the  troops,  in  that  they 
enable  us  to  follow  the  variations  of  venereal  con- 


508  SYPHILIS  AND   THE  ARMY 

tamination,  and  appreciate  the  results  of  prophylactic 
measures,  they  give  but  a  very  incomplete  idea  of  the 
frequency  of  syphiUs  amongst  a  military  population. 
If  it  were  possible  to  register  the  total  number  of  con- 
taminations, this  would,  I  believe,  work  out  at  4,000 
to  5,000  per  month,  say  50,000  to  60,000  per  annum, 
which  for  three  years  of  war  would  make  150,000  to 
180,000  contaminations. 

Pautrier,  chief  of  the  venereological  centre  of  the 
eighth  district  (Bourges),  in  February  1916,  observed 
724  cases  of  primary  or  secondary  syphilis  amongst 
hospital  patients,  or  those  who  came  to  consult  hiili. 
This  centre  had  only  been  worked  from  the  month  of 
September  1915,  that  is,  for  the  period  of  six  months. 

"  If  one  considers,"  he  says,*  "  that  the  venereo- 
logical centre,  unfortunately,  does  not  yet  receive  all 
the  cases  of  syphilis  in  the  district,  a  certain  number 
of  patients  being  wrongly  detained  in  general  or  regi- 
mental hospitals,  while  others  suffer  from  syphilis 
unrecognised  by  the  medical  man  or  concealed  by  the 
patient,  and  if  one  must  admit  without  exaggeration 
that  this  calculation,  to  be  correct,  should  be  mul- 
tiplied by  4  or  5,  one  sees  what  an  impressive  total 
would  be  reached  in  the  eighth  district  alone.  By 
multiplying  this  number  by  that  of  twenty  other 
territorial  districts  and  adding  the  very  considerable 
figure  of  the  army  zone,  it  is  possible  to  conceive  that 
the  cases  of  syphilis  contemporaneous  with  the  war 
will  not  be  reckoned  by  tens  of  thousands,  but  by 
hundreds  of  thousands." 

He  considers  that  200,000  syphilitics  will  be  a  highly 
probable  number. 

*  Pautrier,  "  On  the  General  Organisation  of  Military  Venereal 
Hospitals  and  of  the  Annexed  Services."  Report  presented  at 
the  Meeting  of  the  Heads  of  the  Venereological  Centres,  held 
July  13th,  1916  {Annales  de  dermatologie ,  September  1916,  p.  233). 


CHAPTER    II 

ON  THE  ORIGIN  OF  SYPHILITIC  CONTAGION  IN  THE  ARMY 

As  may  be  supposed,  the  origins  of  syphilitic  con- 
tagion in  the  Anny  are  multiple. 

It  is  frequently  difficult  to  determine  them.  All 
patients  do  not  lend  themselves  to  investigation  with 
equal  readiness  :  some  have  contracted  syphihs  under 
circumstances  which  they  do  not  care  to  divulge  ; 
others  refuse,  from  a  spirit  of  chivalry,  to  denounce 
the  woman  who  accorded  them  a  favour,  whether 
gratuitous  or  paid  for  ;  some,  on  account  of  drunken- 
ness, are  unable  to  give  either  place,  time  of  meeting, 
profession,  or  colour  of  the  hair  of  their  temporary' 
partner  ;  while  others,  again,  have  had  so  many  and 
such  frequent  adventures  with  different  women  that 
they  are  unable  to  blame  one  more  than  another. 

Despite  the  difficulties  of  the  inquiry,  a  certain 
number  of  soldiers  have  replied  to  the  questions  with 
apparent  veracity,  and  medical  men  have  been  able  to 
obtain  information  of  sufficient  accuracy. 

Some  of  these  inquiries  have  been  pubhshed,  and 
they  contain  a  sufficient  number  of  names  to  be  of 
value,  especially  those  of  Jolivet  and  Carle. 

Take  first  Jolivet' s  *  inquiry,  which  contains  a  list  of 
the  first  100  venereal  patients  treated  in  an  infectious 
hospital  in  the  army  zone,  and  the  information  he 

*  Jolivet,  "  Origin  of  the  Contamination  of  100  Venereal  Patients 
treated  in  the  Army  Zone"  {Annales  de  dermatologie.  May  191G, 
p.  126). 

509 


510  SYPHILIS   AND   THE   ARMY 

was  able   to  obtain  as  to   the  manner  of  their  con- 
tamination. 


s 

yphilis . 

Gonori'hoe 

\.    Simple  Chancre 

I.- 

-Official  Pi'ostitution,  52 °o 

Houses      .... 

16 

10 

— 

Meeting-houses 

— 

1 

— 

Licensed  prostitutes 

9 

14 

2 

II.- 

—Clandestine  Prostitution,  48% 

'  Dressmakers 

— 

1 

— 

Laiuidresses 

1 

1 

— 

Married     Publicans    . 

1 

. — 

— 

Women 

Profession  tinknown 

2 

2 

— 

Legitimate  wives 

3 

13 

— 

,  Refvigees     . 

2 

— 

—  ' 

Legitimate  mistresses 

I 

1 

— 

Laundresses 

3 

2 

— 

Work-wonien     . 

2 

4 

— 

Waitresses  in  cafes 

1 

4 

— 

III. 

— Category  Undetermined   . 

1 

—  ■ 

— 

IV. 

— Extra-genital  Contagion  (?) 

] 

— 

n  in  army. 

V.- 

-Contagion  from  pederastic  acts 

— 

— 

2  j  1  in    hos- 

^     pital. 

Carle  *  has  obtained  statistics  giving  the  mode  of 
contamination  of  291  men  observed  in  the  venereolo- 
gical  centre  of  an  army. 

These  two  statistics  are  particularly  interesting, 
because  they  both  of  them  treat  of  contaminations 
incurred  as  much  in  the  army  zone  as  in  the  interior  ; 
thus  allowing  comparison  of  the  mode  of  syphihtic 
dissemination  in  two  entirely  different  centres. 

The  following  statistics,  prepared  by  Madame 
Oovaerts  with  scrupulous  accuracy,  record  165  syphi- 
litic men  observed  in  my  chnic  in  the  St.  Louis  Hospital, 
from  February  15th  to  August  15th,  1916,  and  in  these 
cases  it  was  possible  to  trace  the  origin  of  contamination. 

*  Carle,  "  Three  Months'  Work  in  the  Dermatological  and  Venereo- 
logicai  Sections  of  an  Ai-my.  Ambulance.  Statistical  and  critical 
Gtudy  "  {Archives  de  Medecine  et  de  Pharmaciemilitaires,  June  1916, 
p.  865). 

Carle,  "  Prophylaxis  of  Venereal  Diseases  in  the  Army.  Measures 
taken,  Measures  to  be  undertaken."  Report  at  the  Meetinig  of  the 
Heads  of  the  Venereological  Centres,  July  13th,  1916.  {Annales 
des  maladies  veneriennes.  September  1916,  p.  536.) 


SYPHILITIC   CONTAGION   IN   THE   ARMY^W 

The  statistics  refer  to  both  military  and  civil  patients; 
I  thought  it  better  to  combine  them  in  the  same  table, 
in  order  to  show  that,  in  the  interior,  the  majority 
of  syphiUtic  contaminations  are  due  to  prostitution, 
amongst  the  civil  as  well  as  amongst  the  mihtary 
population. 

It  is  interesting  to  determine  the  source  of  syphi- 


Army  Zone. 

Interior. 

General 
Total. 

Total. 

Gonorrhoea. 

Syphilis. 

Total. 

Gonorrhoea. 

Syphilis. 

Legitimate  wives 

(to  their  hus- 
bands) 
Married  women 

12 

1 

1 

— 

11 

7 

4 

(townswomen 
and   farmers' 

wives)  . 

43 

31 

24 

7 

12 

7 

o 

Work- women    , 

24 

14 

8 

6 

10 

o 

5 

Servants       and 

cooks   . 

13 

5 

3 

2 

8 

5 

3 

Farm-girls,     or 

girls    met    on 

farms   . 

17 

15 

8 

7 

2 

2 

— 

Waitresses 

33 

12 

7 

5 

21 

*i 

15 

Landladies 

78 

17 

10 

7 

61 

40 

21 

Professionals, 

either  licensed 

or  clandestine 

71 

18 

14 

4 

53 

40 

13 

Total   . 

291 

113 

75 

38 

178 



112 

66 

litic  contagion  separately  in  the  different  military 
classes  :  soldiers  at  the  front,  those  in  the  depots  and 
sedentary  services,  and  men  mobiUsed  in  munition 
works. 

Men  at  the  front  may  be  contaminated  either  in 
the  Army  or  the  interior ;  statistics  show  that  they 
become  affected  much  more  frequently  in  the  interior 
than  in  the  army  zone. 


512            SYPHILIS 

AND 

THE 

ARMY 

Source  of  Contamznation  in 

165 

Syphilitic  Patients  observed 

IN  MY  Clinic 

(February  15th  to  August  15th,  1916) 

to  tn 

Patient 

Patient 

J 

"S 

m 

S-s 

could  not 

denied 

d 

1 

'S 

Si 

1 

3 

Class  of  Patients. 

1 

O 
'to 

S-l 

a  o 
S  to 
O  0 

01"  would 
not  give  in- 
formation. 

extra- 
conjugal 
intercourse. 

a 

o 

1 

u 
o 

3 

Wives  or  mis 
tresses  with 
whompatien 
had  lived  for 
a  long  time. 

Probable  contamination 
by  professionals. 

Military 

31 

20 

I 

2 

1 

1  (wife; 

Mobilised  workmen 

21 

12 

1 

3 

2 

— 

1  (mis- 
tress; 

Rejoined 

37 

22 

1 

3 

1 

4 

3 

3  (mis- 
tresses; 

'16  to  20  years  of  age  . 

24 

15 

2 

— 

— 

6 

1 

... 

3  of  20         „       „ 

H 

7  „  19         „       „ 

«  m 

8  „  18         „       „ 

4  „  17         „       „ 

•S'P 

2  „  16         „       „ 

o  ••■ 

g.2 

20  to  50  years  of  age  . 

42 

28 

1 

5 

1 

4 

I 

I  (wife; 

Half    of  these  are  of 

I  (mis- 

foreign nationality 

— 

— 

— 

— 

— 

— 

— 

tress;' 

^i 

50  to  73  years  of  age  . 

10 

2 

— 

3 

2 

2 

1 

is 

7  of  50  to  60 yrs.  of  age 

1  „  64    „      „ 

tH 

1  „  66    „      „ 

1 

^  1  ,,  73    ,,      ,,         ,, 

9 

Total 

— 

99 

6 

15 

8 

21 

7 

Jolivet,  whose  inquiry  yielded  100  cases  of  venereal 
disease,  observed  in  an  infectious  hospital  near  the 
front,  gives  the  following  table  : 


Syphilis.      Gonorrhoea. 
Men  contaminated  in  the  , 

army  zone  (24%)  .  11  11 

Men  contaminated  in  the  I  ,        ,         ty. 
interior  (76o/„)     .  .latve's 


13 
29 


Simple 
Chancre. 


Carle,  out  of  291  men  under  observation  in  the 
venereological  centre  of  the  Army  (see  Table  on  page  9). 
takes  178,  i.e.  61%,  as  having  been  contaminated  in 


SYPHILITIC  CONTAGION  IN  THE  ARMY  ^V^ 

the  interior.  In  a  series  of  238  cases,  more  recently 
observed,  he  counts  170  contaminations  coming  from 
the  interior,  i.e.  71%. 

In  adding  together  the  totals  of  these  three  statistics, 
out  of  629  cases  of  venereal  disease,  524  contagions  are 
from  the  interior,  i.e.  73* 6%. 

Tzanck  has  communicated  the  following  statistics  to 
me  ;  they  were  obtained  in  a  miHtary  venereal  centre, 
and  bring  more  evidence  to  bear  upon  the  part  played 
by  prostitutes  in  syphilitic  contamination  at  the  base. 


Free  prostitutes 
Landladies 
Servants 
Married  women 
Legitimate  wives 

Total 


Syphilis  contracted 

At  the  Front 

At  the  Base 

.      6 

140 

-: — 

2 

.      2 

6 

.     — 

8 

— 

1 

157 


Hence,  soldiers  at  the  front  most  frequently  contract 
syphilis  in  the  interior,  either  in  the  depots  before 
returning  to  the  front,  or  when  on  leave. 

Men  on  leave  have  various  opportunities  of  con- 
tracting venereal  disease  :  from  the  moment  of  quitting 
their  unit  they  pass  through  towns  in  the  miUtary 
zone  where  syphiUs  is  rampant,  and  stop  at  railway 
and  transport  junctions,  often  in  Paris,  where  the 
station  approaches  are  seething  with  women  of  aU  kinds. 
JoUvet,  out  of  100  patients,  cites  no  less  than  6  cases 
(2  syphihs,  4  gonorrhoea)  contracted  from  women  near 
railway  stations  by  men  passing  through  the  towns.  I 
have  heard  authoritatively thatmenhave  even  been  con- 
taminated in  the  train  taking  them  on  leave  by  women 
who  walk  the  trains  and  succeed  in  escaping  observation. 

At  the  place  of  destination  there  are  various  sources 
of  contagion  :  barmaids,  waitresses,  laundresses,  and 
work -girls  give  themselves  up  to  clandestine  prostitu- 
tion ;  there  is  also  the  mistress  who,  abandoned  on 
mobiUsation,  has  since  taken  one  or  more  lovers.    Men 


51i  SYPHILIS   AND   THE  ARMY 

Avho  have  been  mobilised  longest  sometimes  incriminate 
their  wives  :  medical  men  at  the  front  cannot  verify 
the  accuracy  of  the  statements  of  their  patients,  and, 
despite  the  number  who  assert  that  their  wives  have 
contaminated  them  (16  in  Johvet's  statistics,  11  in 
Carle's),  may  be  sceptical.  Facts  observed  in  the 
interior,  of  women  infected  in  the  absence  of  their 
husbands,  and  dreading  to  infect  them  when  on 
furlough,  leave  no  doubt  as  to  the  reaHty  and  re- 
latively large  number  of  these  contagions.  Indeed, 
it  has  occasionally  been  possible  to  examine  the 
husband  when  on  subsequent  leave,  and  make  an 
a,ccurate  inquiry  into  the  evolution  of  the  two  infec- 
tions with  syphihs.  I  myself  have  seen  more  than 
forty  absolutely  authentic  cases. 

In  the  army  zone,  contamination  mostly  emanates 
from  women  whose  business  brings  them  in  contact 
with  soldiers  :  restaurant  keepers,  barmaids,  laun- 
dresses to  whom  the  men  send  their  washing  on 
returning  to  quarters  ;  seamstresses,  who  mend  their 
clothes,  as  well  as  farm-girls  met  near  camp,  or  in  the 
open  country.  Often  the  women  are  married  (31  out 
of  113  contaminations  in  the  army  zone,  according 
to  Carle's  statistics),  town  or  country  women;  these 
latter  are  almost  as  numerous  as  professionals,  regis- 
tered or  clandestine,  free  or  in  houses,  mentioned  in 
the  same  statistics  (35  professionals  as  against  32 
married  women). 

To  sum  up,  in  the  army  zone,  venereal  diseases  are 
transmitted  more  often  by  women  who  are  not  pro- 
fessional prostitutes  than  by  official  or  clandestine 
prostitutes  living  solely  by  their  bodies.  If  one  could 
separate  the  contaminations  occurring  in  large  towns 
and  at  the  base  from  those  occurring  in  the  army  zone, 
the  part  played  by  true  prostitution  in  the  dissemina- 
tion of  syphihs  and  venereal  diseases  in  the  immediate 
neighbourhood  of  the  front  would  be  very  considerably 
diminished. 


SYPHILITIC  CONTAGION  IN  THE  ARMY  515 

In  the  Table  published  by  Carle  a  suggestive  com- 
parison may  be  made  of  venereal  contaminations  by 
professionals,  according  to  whether  these  were  produced 
in  the  army  zone  or  in  the  interior  ;  in  the  latter  they 
give  114  contaminations  out  of  178,  i.e.  64%,  and  in 
the  army  zone  35  out  of  113,  i.e.  31%,  or  less  than  half. 

There  is,  therefore,  a  danger  to  soldiers  in  women 
who  are  apparently  most  innocent,  and  the  importance  • 
of  this  cannot  be  exaggerated.  I  even  heard  some 
mihtary  surgeons  say  that  every  woman  in  the  war 
zone  ought  to  be  watched,  and  that  no  social  position 
should  prevent  the  suspicion  of  syphihs  from  being 
traced  to  its  lair.  Proportionally  as  the  war  is  pro- 
longed, the  opportunities  for  these  women  contracting 
syphihs  will  be  multiphed,  with  consequent  increase  in 
the  dangers  run  by  the  troops. 

Syphihs  is  very  irregularly  distributed  in  the  different 
bodies  of  troops,  and  I  could  cite  such  and  such  a 
regiment  in  which  the  number  of  cases  of  syphihs  is 
at  the  lowest,  although,  and  perhaps  because,  medical 
inspection  is  made  regularly  and  carefully.  In  others, 
on  the  contrary,  syphihtic  morbidity  is  high.  These 
inequahties,  for  the  greater  part,  are  due  to  the 
sanitary  condition  of  the  women  with  whom  the  men 
have  intercourse  :  owing  to  the  small  number  of 
women  hving  near  the  front  zone,  it  only  requires  a 
few  of  them  to  become  syphihtic  for  contamination  to 
multiply  with  extreme  rapidity.  Equahty  amongst 
the  different  bodies  of  troops,  in  this  respect,  tends  to 
re-estabUsh  itself  by  the  movements  of  the  men  on 
furlough. 

In  the  base  zone,  on  the  other  hand,  contagion  origin- 
ates especially  with  professional  prostitutes  who  swarm 
in  the  large  towns  *  in  search  of  soldiers  quartered 

*  L.  SpillmannC  On  the  Increase  of  Syphilitic  Morbidity  among 
Troops  on  Active  Service,"  Comptes  rendua  de  la  Societe  de  Medecine 
de  Nancy,  December  22nd,  1915)  has  noted  the  increase  in  the 
number  of  prostitutes  at  Nancy.  This  has  also  been  reported  to 
me  from  all  the  large  towns  near  the  front. 


516  SYPHILIS  AND   THE  ARMY 

in  these  towns,  and  with  other  women  brought  there 
by  their  duties,  or  passing  through  when  on  furlough. 
For  some  time  there  has  not  been  one  of  these  large 
towns  in  which  syphiUs  has  not  made  an  incessant 
advance  ;  statistics  are  wanting  as  to  the  sanitary 
condition  of  these  towns,  but  the  declarations  of  both 
civil  and  mihtary  surgeons,  and  the  afflux  of  syphihtic 
women  into  the  hospitals,  prove  it  abundantly.  It  is 
in  these  towns  that  the  most  rigorous  super\'ision  of 
both  official  and  clandestine  prostitution  should  be 
exercised. 

The  risks  of  contamination  in  the  base  zone  explain 
why  syphilis  is  extremely  frequent  amongst  men  staying 
there,  or  who  have  easy  access  ;  such,  for  example,  as 
the  staffs  of  aviation  camps,  motor-drivers,  secretaries 
of  the  general  staff,  amongst  whom  a  high  proportion  of 
syphilitic  cases  have  been  observed  by  the  medical  men. 

In  the  depots  and  sedentary  services,  the  sources  of 
contamination  are  similar  to  those  noted  with  men  on 
leave.  They  are,  as  in  times  of  peace,  but  in  higher 
degree,  prostitutes  of  all  kinds.  Statistics  of  my 
cUnic  show  that,  out  of  31  syphihtic  soldiers,  20  had 
been  contaminated  by  avowed  professionals,  and  3 
others  also  probably  by  professionals.  In  these  20 
contaminations  it  was  always  a  case  of  sohcitation, 
especially  around  the  Paris  railway-stations  and  near 
the  depots.  We  thus  come  to  a  proportion  of  64,  or 
perhaps  70%  of  infections  by  prostitutes.  Comparing, 
in  the  same  statistics,  the  round  numbers  (civil  and 
mihtary  combined)  of  cases  observed  (165)  with  those 
of  the  contaminations  emanating  from  professionals 
(which  extend  certainly  to  99,  and  probably  to  122), 
a  similar  percentage  is  reached,  which  shows  that  60 
and  probably  73%  of  the  contaminations  are  due  to 
professionals. 

Meetings  take  place  on  the  public  highway,  near  the 
Paris  railway  stations,  in  mihtary  centres,  at  depots, 
concerts,  cinemas,  etc. 


SYPHILITIC  CONTAGION  IN  THE  ARMY  517 

For  men  mobilised  in  munition  works,  the  habitual 
source  of  syphiUtic  contagion  is  also  the  prostitute,  at 
least  in  Paris.  In  provincial  towns,  it  is  more  likely 
to  be  caught  in  the  workshop  :  the  promiscuity  of  the 
sexes  entailed  by  the  necessities  of  work,  and  more 
especially  its  inspection  (women  being  inspected  by 
foremen)  facihtates  more  or  less  durable  liaisons,  with 
resultant  contaminations.  It  is  noteworthy  that  a 
certain  number  of  pre-war  prostitutes,  whose  clientele 
had  been  reduced  by  mobilisation  enrolled  themselves 
amongst  munition  workers.  It  has  been  stated  that, 
in  a  large  provincial  town,  the  majority  of  certified 
prostitutes  were  engaged  in  munition  work ,  their  wages 
increasing  the  profits,  reduced  by  war,  of  prostitution, 
which  they  continued  to  practise  with  their  fellow- 
workmen. 

Non-venereal  contaminations  occur  in  the  Army  ; 
the  proximity  of  the  trenches  and  camps,  the  common 
interchange  of  mugs,  forks,  pipes,  etc.,  are  sufficient 
to  explain  these.  Cuts  from  the  improvised  barber's 
razor,  often  a  poor  one,  may  also  produce  syphiHtic 
infection. 

As  a  matter  of  fact,  however,  despite  inadequate 
precautions,  such  contaminations  appear  to  be  rare 
in  the  Army. 


CHAPTER    III 

SYPHILIS   AS   A   NATIONAL   DANGER 

There  is  no  exaggeration  in  stating  that  the  present- 
day  frequency  of  syphihtic  contamination  constitutes 
a  danger  of  the  first  importance,  which  will  have  an 
influence  upon  the  nation  quite  as  considerable  as  that 
of  the  most  deadly  epidemics.*  This  danger  can  only 
be  compared  to  that  of  tuberculosis,  against  which  it 
is  Justifiable  to  take  .the  most  rigorous  and  expensive 
precautionary  measures. 

Before  showing  of  what  these  dangers  consist,  the 
modes  by  which  the  propagation  of  syphilis  under- 
mines the  national  defence,  compromises  the  vitality 
of  the  nation,  racial  vigour,  and  the  repopulation  of 
France,  it  may  be  well  to  complete  the  picture  of 
syphiHs  in  this  country  and  to  sketch  rapidly  its  present 
effect  on  the  civil  population. 

Syphilis  amongst  the  Civil  Population  since  the 
Beginning  of  Hostilities 

In  the  preceding  chapter  I  indicated  the  frequency 
and  origin  of  syphilis  in  the  Army,  and  the  influence 
of  the  civil  upon  the  mihtary  environment. 

Like  all  contagious  diseases,  and  more  especially  for 

*  This  is  no  new  danger,  nor  is  it  the  result  of  the  present  war 
alone.  Landouzy  ("Syphilis  before  the  War.  -Disregard  of  its 
extreme  Frequency,"  Bulletin  de  V Academic  de  Medecine.  Meeting 
of  April  18th,  1916,  p.  434)  has  shown  with  great  force  and  appro- 
priateness that  it  has  long  been  in  existence,  and  has  remained  xm- 
sxispected  by  far  too  ra^ny. 

518 


SYPHILIS  AS   A    NATIONAL  DANGER  519 

the  majority  of  them,  endemic  syphilis  in  the  Aniiy 
does  not  limit  its  effects  to  the  soldiers  themselves,  but 
has  an  immediate  and  extensive  repercussion  upon  the 
civil  population.  The  conditions  of  syphiHtic  trans- 
mission explain,  without  further  detail,  this  exchange, 
which  is  far  too  free.  Let  us  see  how  this  influence  of 
a  mihtary  centre  affects  civil  life. 

Here,  again,  available  statistics  are  wanting.  Syphi- 
litic morbidity  of  different  social  districts  in  times  of 
peace  is  subject  to  variations,  difficult  to  disentangle 
from  a  rough  accumulation  of  figures,  and  these  social 
centres  have  been  upset  by  the  war.  The  influx  of 
refugees  has  modified  the  population,  especially  the 
number  of  those  attending  the  hospitals  :  the  utiUsa- 
tion  of  female  labour  has  changed  the  composition  of 
workshops,  causing  an  influx  of  women  of  restricted 
means ,  forced  by  the  war  to  earn  their  own  Hv  ing.  What 
can  I  say  further  ?  In  the  hospital  clinics  the  propor- 
tion of  syphiUtic  cases  recently  reported,  among  the 
total  number  in  hospital,  would  seem  to  indicate  an 
increase  of  syphiHs ;  but  the  conditions  of  admission 
to  hospital  of  cutaneous  affections  are  quite  different 
to  those  of  peace  time  :  refugees  are  sent  to  hospital  for 
benign  diseases  which  would  have  been  treated  at  home  ; 
patients  suffering  from  chronic  affections  have  left 
hospital  to  work,  etc.  The  result  is,  without  counting 
that  the  diminution  in  number  of  medical  students  does 
not  allow  of  the  collection  of  all  facts  from  the  hospital 
statistics,  that  these  statistics  do  not  contribute  ele- 
ments of  certainty  to  the  study  of  the  increase  of 
syphiHs. 

It  is  imperative,  therefore,  to  abide  by  the  impres- 
sions of  medical  men;  and  all  declare  that  syphihs 
has  increased,  not  only  speciaHsts,  but  general  practi- 
tioners as  well. 

Brocq  *  wrote  in  January,  1916  :    "I  shall  not,  in 

*  Brocq,  •'  The  Influence  of  the  Present  War  on  Cutaneous 
Affections"  {Bulletin  medicale,  January  22nd,  1916,  p.  111). 


520  SYPHILIS   AND   THE   ARMY 

this  note,  insist  upon  the  heartrending  frequency  of 
venereal  diseases,  and  the  terrible  increase  in  syphilis 
since  the  beginning  of  hostilities  :  my  sole  occupation 
to-day  will  be  cutaneous  affections  properly  so-called, 
and  yet  I  cannot  state  too  emphatically  that  the  true 
aspect  of  our  clinics  during  the  war  is  dominated  by  > 
the  deplorable  prevalence  of  syphilis." 

A  very  distinguished  doctor,  belonging  to  an 
Accidental  Insurance  Company,  Dr.  Borne,  recently 
informed  me  that,  whereas  before  the  war  he  rarely 
saw  one  patient  a  month  in  whom  he  could  find  a 
trace  of  venereal  disease,  syphilitic  eruptions,  mucous 
plaques,  gonorrhoeal  arthritis,  etc.,  at  the  present 
time  he  comes  across  three  to  four  per  week. 

There  is  no  doubt  that,  in  a  general  way,  the  number 
of  cases  of  recent  syphilis  has  increased  amongst  the 
civil  population  since  the  war,  and  there  is  evidence 
of  still  further  advance.  I  repeat,  this  is  the  result 
observed,  from  the  discussions  I  have  had  with  a 
number  of  medical  men,  all  of  whom  have  confirmed 
these  statements. 

This  does  not  apply  specially  to  Paris  ;  it  has  been 
observed  by  all  medical  men  I  have  questioned,  both 
in  large  centres  and  small  localities. 

Indeed,  not  only  is  the  increase  of  syphilis  observed 
in  Paris  and  large  towns  ;  it  has  also  been  noted  in 
small  towns  and  localities  soon  after  a  military  influx 
(near  the  front,  in  training  camps,  especially  quarters 
at  the  base,  in  the  rest  billets,  depots  for  troops, 
motor  and  aviation  centres,  hospitals,  etc.),  and  among 
munition  workers.  It  is  even  relatively  perhaps  more 
important  in  small  localities  than  in  big  towns,  where 
syphilis  has  always  been  present. 

There  are  two  civil  classes  especially  in  which  this 
augmentation  has  been  surprising  :  amongst  married 
women  and  young  men. 

All  medical  men  at  special  hospitals  have  noted 
that   the  number  of    married  women  who    come  to 


SYPHILIS   AS   A    AATIONAL  DANGER  521 

consult  them  for  syphilitic  troubles  is  altogether 
abnormal,  and  out  of  proportion  to  what  occurred 
in  time  of  peace. 

I  learn  from  Louis  Spillmann  that  the  number  of 
married  women  in  hospital  at  the  Nancy  free  venereal 
clinic,  which  in  1914  was  5,  with  1  syphilitic,  had  in 
1916  risen  to  43,  with  23  syphilitics. 

Of  these  women,  some  contracted  syphilis  from  a 
civilian  of  some  kind,  a  man  recalled  to  the  colours, 
or  too  old  for  military  service,  or  from  a  refugee  met 
by  accident  in  the  workshop  or  the  street ;  here, 
there  is  no  difference  from  what  is  seen  in  time  of 
peace.  Others  have  contracted  the  disease  from  men 
at  the  depots,  munition  workers,  soldiers  on  leave  or 
under  treatment  in  the  hospitals. 

These  two  classes  comprise  women  of  varying 
morality,  some  of  whom  only  had  recourse  to  extra- 
conjugal  relations  as  a  means  of  augmenting  their 
incomes,  which  had  been  reduced  since  the  departure 
of  their  husbands. 

By  the  side  of  these  are  the  ivomen  contaminated  hy 
their  husbands  home  on  leave,  or  returned  home  after 
being  discharged  wounded.  These  women  are  un- 
doubtedly syphilitic  owing  to  the  war,  and  they  are 
numerous  :  not  a  single  day  passes  without  two  or 
three,  and  sometimes  more,  presenting  themselves 
at  St.  Louis  Hospital  for  consultation.  They  are  of 
all  ages,  sometimes  young  ;  a  large  number  of  them 
have  no  suspicion  of  what  they  are  suffering  from, 
and  no  idea  of  the  nature  of  the  sore  throat,  roseola, 
or  alopecia  for  which  they  are  seeking  advice.  They 
are  ignorant  of  syphilis  and  its  contagion,  and,  as  a 
rule,  it  would  never  occur  to  them  to  blame  their 
husbands  ;  it  is  only  on  inquiry  that  the  medical 
man,  when  hearing  the  history  of  the  illness,  verifying 
dates,  and,  finding  when  the  husband  came  home  on 
leave,  has  traced  it  to  its  source,  this  being  confirmed 
later  by  the  statement  or  examination  of  the  husband. 


522  SYPHILIS  AND   THE  ARMY 

I  repeat,  these  facts  are  legion  ;   I  myself  having  seen 
above  a  hundred  cases. 

Here,  again,  mention  must  be  made  of  the  munition 
workers.  As  I  have  already  stated,  and  again  repeat, 
an  enormous  proportion  of  these  men  are  syphilitic, 
and,  despite  every  possible  advice,  many  of  them  take 
no  care  of  themselves  at  all.  The  result  is  the  frequent 
contamination  of  their  wives,  whether  these  live  at  a 
distance  or  have  remained  with  their  husbands.  I 
have  already  seen  a  large  number  of  married  women 
whose  husbands,  munition  workers,  had  infected  them. 

All  these  women,  respectable  mothers  of  families, 
sometimes  pregnant  or  having  been  recently  con- 
fined, are  totally  ignorant  of  syphilis,  or  of  the  fact 
that  they  may  contaminate  their  children.  On  several 
occasions  I  have  seen  two  or  three  children  brought 
to  me  suffering  from  chancres  transmitted  to  them  by 
their  mothers — this  would  be  an  exceptional  occurrence 
in  peace  time,  when  the  majority  of  syphilitic  women 
treated  in  hospital  know  how  to  account  for  their  illness. 

Another  fact  which  has  struck  all  medical  men  is 
the  frequency  of  syphilis  in  young  men  since  the  war 
began.  There  is  no  day  in  which  several  do  not 
come  up  for  consultation  ;  at  the  St.  Louis  Hospital,  I 
myself  never  see  less  than  two  or  three  at  each  con- 
sultation, from  16  to  18  years  of  age.  They  have 
generally  contracted  the  disease  from  some  woman 
met  in  the  street,  the  suburbs,  or  on  the  outer  boule- 
vards. There  is  little  doubt  that  they  have  listened 
to  her  solicitations  :  won't  they  soon  be  soldiers,  and 
must  they  not  now  prove  their  manhood  ?  When 
questioned,  many  of  them  reply,  with  a  certain  conceit, 
that  they  cannot  say  what  day  they  were  affected, 
as  the  occasions  had  been  numerous.  Then,  again, 
there"  are  a  number  of  women  on  the  streets,  many  of 
them  "  unemployed  "  owing  to  the  reduction  of  the 
male  population  of  the  suburbs,  and  they  have  much 
to  answer  for  in  juvenile  contamination. 


SYPHILIS  AS  A   NATIONAL  DANGER  523 

These  young  syphilitics  are  the  soldiers  of  to-morrow  : 
military  surgeons  have  reported  with  horror  the 
proportion  of  recent  cases  of  sypMlis  amongst  the 
youths  who  have  joined  up  during  these  last  months. 

The  Social  Consequences  of  Syphilis 
AMONGST  Soldiers 

To  return  to  syphilis  amongst  soldiers. 
On  account  of  its  frequency  amongst  soldiers  and 
munition  workers,  this  has  become  a  danger  : 

1.  Because  it  compels  patients  to  submit  to  treat- 
ment which,  during  the  contagious  periods,  cannot 
be  carried  out  at  the  front,  or  while  men  are  still 
engaged  in  munition  works,  because,  in  a  word,  it 
diminishes  the  effectives. 

2.  Because  it  diminishes  a  7nan^s  value. 

3.  Because,  being  transmissible  to  a  patient's 
descendants,  it  coinpromises  the  race  at  an  epoch  when, 
more  than  ever  before,  it  is  imperative  that  the  race 
should  be  numerous  and  robust. 

Diminution  of  Effectives. — ^^In  order  to  reduce 
syphilitic  propagation,  whether  genitally  or  extra- 
genitally,  it  is  essential  that  the  patient  should  be 
removed  from  his  habitual  environment — from  his 
work  or  duty— -as  long  as  he  is  a  carrier  of  contagion  : 
this  is  a  fact  disputed  by  no  one.  This  precaution  is 
all  the  more  necessary  because  genuinely  effective 
treatment  of  syphilis  is  not  compatible  with  the 
requirements  of  military  duties  in  time  of  war. 

Moreover,  no  matter  how  intense  and  active  the 
treatment,  in  order  to  sterilise  the  contagious  lesions, 
chancre  or  mucous  plaques,  a  minimum  of  time  is 
required,  which  varies  according  to  the  methods 
employed.  Medical  men,  aware  of  the  necessities  of 
national  defence,  endeavour  to  reduce  this  period ; 
but,  owing  to  the  number  of  syphUitics,  it  represents 
a  very  appreciable  time,  and  consequently  a  waste 
of  effectives. 


524  SYPHILIS  AND   THE  ARMY 

Further,  syphilis,  even  at  an  early  stage,  and  espe- 
cially if  not  treated  effectively  at  the  beginning,  may 
give  rise  to  lesions  which  necessitate  more  or  less 
prolonged  treatment  in  hospital,  so  as  to  avoid  con- 
tagion :  jaundice,  albuminuria,  headache,  ulcerative 
cutaneous  lesions,  etc.,  which  form  one  part  in  the 
percentage  of  army  morbidity. 

It  must  be  noted,  also,  that  syphilis  may  play  a 
part  in  the  progress  of  wounds,  retard  their  cicatrisa- 
tion and  osseous  consolidation,  and  perhaps  facilitate 
infection.  From  what  I  know  of  the  operative  results 
on  syphilitic  cases  in  general,  and  what  I  have  seen 
since  the  outbreak  of  hostilities,  this  part  seems  very 
restricted  ;  still,  certain  surgeons  consider  it  of  real 
importance.  It  must,  therefore,  also  be  included 
when  estimating  the  influence  of  syphilis  on  the 
diminution  of  effectives. 

Diminution  of  Men's  Value  and  of  the  Duration  of 
Human  Life. — Syphilis,  during  its  various  periods  and 
for  a  long  time,  causes  a  series  of  lesions  and  troubles 
which  diminish  the  physical  and  intellectual  power 
of  man.  This  is  not  the  place  to  describe,  nor  even 
to  enumerate  the  cerebro-spinal,  cardio-vascular, 
hepatic,  renal,  and  osseous  localisations  which,  while 
often  attributed  to  other  causes,*  are  none  the  less 
a  part  of  syphilitic  infection  and  gravely  encumber 
statistics  of  morbidity  and  mortality. 

There  are  no  statistics  in  existence  which  enable 
one  to  estimate  the  reduction  of  human  power  entailed 
by  the  morbidity  and  mortality  of  syphilis.  It  would 
be  necessary  to  take  into  account  the  loss  of  time  and 
money  caused  by  treatment ;  the  incapacity  to  work 
due  to  the  disease  itself,  and  the  influence  it  might 
exercise  on  different  affections,  especially  infections 
and  intercurrent  intoxications. 

*  Letulle  and  Bergeron,  "  The  Wassermann  Reaction  in  Chronic 
Diseases"  {Bulletin  de  VAcademie  de  Medecine.  Meeting  of 
February  22nd,  1910,  p.  204). 


SYPHILIS   AS  A    NATIONAL  DANGER  525 

As  an  indication,  I  may  refer  to  the  fact  that,  as 
regards  workmen's  accidents,  the  tribunals,  when  they 
have  to  appreciate  the  reduction  of  professional 
capacity  as  the  result  of  syphilis,  fix  this  reduction 
between  15  and  25%. 

In  order  to  give  an  idea  of  the  relative  frequency  of 
later  syphilitic  manifestations,  Fournier  *  compiled  a 
Table  giving  the  results  of  the  examination  of  4,000 
patients  who  had  consulted  him  for  tertiary  symptoms. 
The  folio  wins;  is  a  resume  of  this  Table  : 


Syphilides  and  guinmata 
Lesions  of  genital  organs   . 
,,         ,,  the  tongue  and  lips 
,,         ,,  the  pharynx  and  palatine  arch 
,,         r,  of  bones  and  of  the  nose 
Gummata  of  tendons  and  muscles 
Lesions  of  the  digestive  tube 

,,    respiratory  passages 

,,    heart,  aorta,  and  arteries 

,,    liver   . 

„    kidney 

,,    testicle 

.-,    ^ye     . 

.,    ear 
SyphiUs  of  the  brain  . 
Cerebro- spinal  troubles 
Sj'phiLis  of  the  medulla 
Tabes 

Neuritis  and  muscular  atrophy 
General  paralysis 
Ocular  paralysis 
Facial  hemiplegia 
Sundry  nervous  affections 
Sundry  localisations   . 


1,655 

271 

304 

566 

541 

19 

21 

55 

22 

9 

31 

245 

110 

24 

764 

29 

135 

676 

24 

83 

120 

23 

13 

19 

5,749 


As  regards  syphilitic  mortality,  Blaschko,t  drawing 
upon  the  statistics  of  insurance  companies,  comes  to 


=^  Alf .  Fo\irnier,  The  Social  Danger  of  Syphilis.  Report  presented 
at  the  First  International  Conference  for  the  Prophylaxis  of  Venereal 
Diseases.     Brussels,  1899. 

t^  Blaschko,  "  The  Influence  of  Syphilis  on  the  Duration  of  Life  " 
(IV.    International  Congress  for  Medical  Insurance,  Berlin,  J  908). 


526  SYPHILIS   AND   THE   ARMY 

the  conclusion  that  the  deaths  caused  by  syphilis 
represent  6%  of  the  total  mortality,  that  at  least 
30%  of  patients  who  have  had  syphilis  die  of  this 
malady,  and  that  syphilis  shortens  the  duration  of 
life  by  four  years. 

Audry  *  has  proved  that  incomplete,  contradictory, 
and  doubtful  results  of  syphilitic  mortality  are  given 
by  the  statistics  of  insurance  companies,  the  various 
statistics  of  mortality  published  and  those  of  tertiary 
syphilis,  and  that  inquiries  into  treatment  in  clinics 
and  the  impressions  of  syphilologists  only  give 
incomplete  facts.  He  has,  nevertheless,  recognised 
that  their  comparison  yields  interesting  results.  The 
impression  obtained  is  that  the  mortality,  in  round 
figures,  of  syphilis,  specific  and  deuteropathic,  approxi- 
mates to  14  or  15%.  It  is  believed  that  in  France 
the  mortality  of  syphilitic  subjects  regularly  treated, 
young  and  sober,  should  not  exceed  4  to  5%,  whereas 
there  can  be  no  hesitation  in  multiplying  this  pro- 
portion tenfold  for  old  men,  drunkards,  and  certain 
decrepid  individuals. 

These  causes  of  sickness  and  death  enter  but  rarely 
into  play  during  actual  war,  but  their  weight  will  be 
felt  more  severely  by  syphiUtics  during  the  followdng 
years,  all  the  more  heavily  as  fatigue,  war  emotions, 
preoccupations  of  all  kinds,  which  will  follow  peace, 
faciHtate  the  development  and  localise  the  disease  on 
an  organism,  which,  healthy  and  immune  from  syphilis, 
would  have  been  able  to  resist  it. 

The  consequence  is  a  waste,  of  which  it  is  impossible 
to  estimate  the  importance.  It  is  hoped,  hoAvever,  that 
the  energetic  treatment  of  primary  syphihs  will  greatly 
diminish  its  proportions,  although  they  cannot  be 
ignored.  Further,  this  waste,  the  direct  consequence 
of  war  syphilis,  will  occur  during  the  years  in  which 
the  nation  has  the  greatest  need  of  the  energy,  the 

*  Ch.  Audry,  "Essay  on  the  Mortality  of  Acquired  Sj'phiiis" 
{Semaine  medicate,  June  2fitb,  1906). 


SYPHILIS  AS   A    NATIONAL  DANGER   527 

physical  and  intellectual  vigour  of  its  children,  in  order 
to  repair  the  disasters  caused  by  the  war,  and  recon- 
struct the  frame-work  of  industry,  instruction,  and 
scientific  personnel. 

Iiuinspicions  Influence  upon  the  Birth-rate  and  Future 
Generations. — It  seems  a  commonplace  remark,  and  yet 
it  is  one  that  must  be  repeated,  that,  after  the  war, 
it  mil  be  necessary  for  the  French  to  produce  many 
children  :  not  only  must  the  birth-rate  fill  up  the  gaps 
in  the  nation  made  by  war,  but,  further,  those  which 
are  the  result  of  many  years'  voluntary  restriction  of 
births.  The  lessons  taught  by  this  war  have  been 
so  cruel  that  a  new  mentahtj'^  \\i\\  spring  up,  quite 
opposed  to  the  old  order,  as  regards  the  procreation 
of  children. 

It  is  imperative  that  the  classes  1935,  1936,  and  the 
following  years  should  exceed  in  numbers  the  classes 
1915, 1916,  and,  even  if  they  cannot  attempt  to  surpass 
them  in  heroism,  then  they  must  do  so  in  physical 
vigour,  so  that  they  may  have  the  maximum  quahties 
of  resistance  and  of  physical  and  intellectual  develop- 
ment, which  will  result  in  a  high  proportion  of  men  fit 
for  mihtary  service. 

But,  wdth  the  propagation  of  syphiHs,  precisely  the 
opposite  result  will  be  obtained.  What  is  the  value 
of  a  syphihtic  as  a  procreator  ?  Nothing  for  several 
years.  Not  very  much  during  subsequent  ones  ;  so 
much  so  that  nearly  all  syphilologists  *  are  of  opinion 
that  marriage  should  be  forbidden  for  four  years  at 
least,  no  matter  how  intense  and  active  f  treatment 
may  have  been,  or  what  the  serum  reaction  may  be. 

Alfred  Fournier  %  for  many  years  has  made  a  study 
of  the  influence  of  syphiHs  upon  future  generations. 

*  Civatte,  "Under  what  Condition  can  the  Marriage  of  Syphilitica 
be  permitted?"  (General  review,  Annates  de  derniatologie,  1907, 
p.  734). 

t  Brocq,  "  The  Question  of  the  Marriage  of  Syphilitics"  [Bulletin 
ine'dicale,  February  21st  and  24th,  1914,  pp.  183  and  197). 

t  A.  Fcfumier,  Syphilitic  Heredity,  Paris,  1891,  p.  89. 


528 


SYPHILIS   AND   THE   ARMY 


He  has  based  his  conclusions  upon  500  observations,  in 
which  he  has  been  able  to  distinguish  paternal  heredity, 
maternal  heredity,  and  mixed  heredity  (father  and 
mother),  and  considers  that  these  three  kinds  of 
heredity  have  the  following  influence  on  the  morbidity 
and  mortalitv  of  the  child  : 


Exclusive  paternal  heredity 
„  maternal         ,,     . 

Mixed  heredity 


Indicatious  of 
Morbidity. 

37% 
84% 


Indications  of 
Mortality. 

28% 
G0% 


These  statistics  show  that  maternal  heredity  has  a 
much  greater  noxious  influence  than  paternal  heredity  : 
the  contamination  of  a  woman  by  her  syphihtic  hus- 
band may  take  place  several  years  after  his  infection, 
thus  pushing  further  back  the  period  during  which 
the  pair  can  have  healthy  children. 

The  noxious  influence  of  syphiUs  certainly  becomes 
more  attenuated  as  the  years  roll  by  ;  not  only  do  the 
number  of  abortions  diminish,  but  the  mortaUty  of 
children  born  at  term  also  decreases  rapidly. 

Alfred  Fournier  *  has  recorded  the  deaths  of  176 
children  out  of  239  pregnancies  in  syphihtic  famiUes, 
and  has  noted  the  date  of  these  pregnancies  in  connec- 
tion with  piaternal  infection  : 


First  year 
Second  year 
Third  year 
Fourth  year 
Fifth  year 
Sixth  year 
Seventh  year 
Eighth  year 
Ninth  year 
Tenth  year 
Eleventh  year 


*  A.  Fournier,  Syphilitic  Heredity,  Paris,  1891,  p.  104 


88 
34 
17 
7 
5 
6 
5 
5 
1 
1 

9 


SYPHILIS   AS   A   NATIONAL  DANGER    529 

Twelfth  year      .....         3 
Eighteenth  year  ....  1 

Twentieth  year  .....  1 


Total  .  .  .  .  .  .176 


Out  of  103  pregnancies,  the  issue  of  a  syphihtic 
father  and  healthy  mother,  and  in  which  the  paternal 
influence  was  noxious,  the  same  author  has  noted  the 
manner  in  which  the  noxious  effect  was  exercised.* 

Children  born  alive,  tiien  immediately  or  soon  affected 
by  congenital  sjrphilis         .  .  .  .  .17 

Children  born  alive,  then  showing  symptoms  of  re- 
tarded congenital  syphilis  ....  2 

Abortions  or  premature  confinements  of  dead  children       4 1 

Children  dead  after  varying  periods  (but  generally 
after  a  short  period),  without  any  evident  specific 
manifestations  .  .  .  .  .  .  .43 

Total .103 


Bar  has  kindly  shown  me  the  observations  made  on 
syphihtic  women  confined  in  the  Tarnier  chnic  from 
January  1st,  1915,  to  August  31st,  1916. 

Those  women  are  regarded  as  syphihtic  who  present 
active  syphihtic  troubles,  proved  syphihtic  antecedents, 
or  whose  blood  (mother's  venous  blood  or  from  the 
cord)  gives  a  positive  Wassermann  Reaction. 

These  statistics  are  interesting,  as  they  enable  us  to 
appreciate  the  injurious  effects  of  syphihs  upon  the 
offspring  of  women  mostly  subjected  to  the  modern 
methods  of  treatment. 

Out  of  a  total  of  118  pregnancies,  the  number  of 
children  hving  at  the  time  the  mother  left  the  chnic 
after  her  last  confinement  is  40,  i.e.  34%. 

But  this  is  taking  a  round  number,  which,  in  order 
to  indicate  the  real  influence  of  syphihs,  should  be 

*  A.  Foamier,  Syphilitic  Heredity,  p.  75. 


.530 


SYPHILIS  AND  THE  ARMY 


Results  of  Pregintancles  of  53  SYPHn.rnc  Women  coNFi>rED  in 
THE  Tarnier  Clinic  from  January  1st,  1915,  to  August 
31st,  1916, 


1. 


Last 

Previous 

Pregnancy. 

Pregnancies 

Pregnancies  prior  to  syphilitic  infection  : 

Miscarriages     ..... 

3 

15 

Children  macerated  or  still-born 

20 

18 

Exeneephalus            .          .          .          . 

I 

- — 

Children    dead    before    mother    left 

hospital        ..... 

3 

— 

Children  died  within  first  year 

— 

.  10 

Living  children         .... 

15 

5 

Pregnancies    appearing    after    syphilitic 

infection : 

Living  children  (certain  or  very  prob- 

able contamination  of  mother  during 

pregnancy)  .           .          .          . 

9 

— 

Dead  children  ( contamination  of  mother 

during  pregnancy) 

•       2 

— 

Liv^Ing  children  born  after  series  of  mis- 

carriages or  still-born  babies  . 

— 

11 

Still-born    children    (albuminuria    of 

mother    before    a     series    of    mis- 

carriages or  still- births ) . 

— 

5 

Condition  of  child  not  known     . 

— 

I 

Total 


53 


65 


subjected  to  an  important  correction,  for  a  certain 
number  of  these  pregnancies  were  anterior  to  the 
woman's  contamination. 

Counting  all  the  pregnancies  as  such,  where  this 
anteriority  is  probable,  we  find  that  out  of  90  preg- 
nancies certainly  posterior  to  the  syphiHs,  there  are 
20  Uving  children,  i.e.  22%. 

By  taking  an  average,  we  come  to  the  conclusion 
that  28%  at  the  most  of  pregnancies  of  syphilitic 
women  yield  a  child  likely  to  live. 

Further,  it  must  be  noticed  that  for  children  of 
the  last  pregnancy,  observations  cease  8  to  LO  days 
after  birth.  How  many  are  there  still  living  at  20 
years  of  age  ? 

Like  time,  anti-syphiUtic  treatment  attenuates  the 
noxious  action  of  heredity.  So,  for  a  very  long  time, 
which  is  longer  still  if  treatment  has  been  inadequate, 


SYPHILIS  AS  A   NATIONAL  DANGER    531 

or  if  syphilitic  symptoms  have  a  tendency  to  reappear, 
the  syphiUtic  man  begets  a  child  unhkely  to  live,  which 
will  either  not  come  to  term,  or  will  die  in  a  few  days. 
And,  further,  not  only  will  the  child  not  Hve,  but, 
according  to  doctrine  still  under  discussion,  it  will 
have  an  injurious  effect  upon  the  woman  who  bore  it  ; 
it  will  infect  her,  render  her  syphihtic,  will  be  the  cause 
of  her  bearing  no  healthy  children  for  several  years, 
and  thus  prolong  the  duration  of  sterihty  in  the  family. 

But  that  is  not  all :  the  syphihtic  man,  who  for 
years  has  been  unable  to  beget  living  children,  will 
for  some  years  longer  be  unable  to  beget  healthy  or 
well-formed  ones.  His  first  child  having  been, 
vulgarly  speaking,  "  rotten,"  his  later  ones  will  be, 
at  any  rate,  "  tainted."  True,  they  hve,  but  are 
often  born  premature^,  and  are  small  and  pallid- 
looking.  At  the  end  of  some  days  or  weeks,  their 
syphilitic  tendency  is  revealed,  their  nostrils  and  hps 
become  covered  with  scabs  and  fissures,  mucous  plaques 
develop  on  their  Hps  and  tongues  ;  if  breast-fed,  the 
discharge  from  these  lesions  often  causes  a  syphihtic 
chancre  to  develop  on  the  nipple  of  the  nurse,  with 
resultant  troubles  of  all  kinds  for  the  parents. 

Later  children  may  be  born  at  term,  and  reveal 
syphihtic  troubles  neither  at  birth  nor  in  the  following 
weeks;  for  some  months  their  development  may  be 
almost  normal,  but  later  on  they  show  signs  of  retarded 
congenital  syphilis,  so  ably  described  by  Alfred  Fournier. 
They  may  be  apparently  healthy,  with  the  exception 
of  some  accident  which  indicates  their  disease  (gumma, 
exostosis,  lesion  of  palate,  testicular  atrophy,  etc.)  ; 
but,  as  a  rule,  they  are  sickly,  badly  formed  children, 
with  weak  bones,  subject  to  chronic  scrofulous 
ulcerations ;  their  genital  organs  are  imperfectly 
developed,  their  cerebral  functions  affected  in  varying 
degrees,  from  intellectual  debihty  or  simple  arrested 
development  to  complete  imbecility  with  or  without 
hydrocephalus. 


532  SYPHILIS  AND   THE  ARMY 

Black  as  this  description  of  syphilitic  degeneration 
appears  to  be,  it  is  but  too  true  and  too  frequently 
reaUsed. 

SyphiUs  is  one  of  the  most  dangerous  enemies  of  the 
race  and  its  preservation,  as  well  as  the  preservation  of 
its  physical  and  intellectual  quahties  ;  with  alcohoHsm, 
and  much  more  than  tuberculosis,  it  deteriorates,  if 
it  does  not  radically  inhibit,  reproduction. 

The  disastrous  influence  of  war  syphiUs  will  be  felt 
throughout  the  whole  country,  not  only  in  towns,  where 
for  a  long  time  syphilis  has  been  one  of  the  causes 
of  the  decadence  of  the  population,  but  also  in  country 
places,  where  previously  it  was  not  very  prevalent. 
Therefore,  the  danger  is  perhaps  greater  in  the  country 
than  in  towns  :  for  one  reason,  as  experience  has 
shown  me,  family  contaminations  are  more  frequent 
and  numerous,  owing  to  the  ignorance  and  habits  of 
the  patients,  and  medical  instructions  are  less  regularly 
followed.  On  the  other  hand,  the  country  may,  so  to 
speak ,  be  regarded  as  the  conservator  of  racial  vigour  ; 
the  best  mihtary  contingents,  from  a  physical  point 
of  view,  come  off  the  land,  and,  after  the  terrible 
bleeding  of  the  war,  it  will  be  more  than  ever  necessary 
to  safeguard  its  population,  which  is  even  now  barely 
sufficient  for  agricultural  purposes. 

True,  all  syphiHtics  are  not  destined  to  die  without 
issue,  or  to  leave  behind  them  offspring  without  value 
in  the  defence  or  enrichment  of  their  country.  Energetic 
and  sufficiently  prolonged  anti-syphihtic  treatment, 
combined  with  the  attenuating  action  of  time,  will 
enable  them  to  procreate  hving  children,  well  developed 
both  physically  and  intellectually  :  all  medical  men  are 
acquainted  with  syphilitics  who,  after  having  been 
treated  by  the  older  methods,  have  been  allowed  to 
marry  after  a  reasonable  time,  and  whose  children,  born 
under  good  conditions,  are  at  the  present  time  serving 
Avith  the  colours.  We  have  all  seen — ^and  I  could 
cite  several — ^the  children  of  syphilitic  parents  who 


SYPHILIS   AS  A    NATIONAL  DANGER  533 

showed  undoubted  manifestations  in  their  early  days, 
but,  as  the  result  of  active  and  careful  treatment, 
developed  physically  and  intellectually  enough  to  be 
regarded  as  fit  for  mihtary  service.  There  is  reason 
to  believe  that  the  intensive  treatment  in  use  at  the 
present  day  will  yield  even  more  satisfactory  results. 

It  must  be  emphasised,  however,  that  this  is  the  lot 
of  patients  who  have  been  well  advised,  carefully 
treated,  and  have  regularly  followed  the  orders  of  their 
medical  attendants. 

Amongst  the  legions  of  syphiUtics  infected  since  war 
began,  it  is  easy  to  imagine  that,  after  the  cessation  of 
hostiUties,  many  of  them,  removed  from  the  supervision 
of  the  medical  man  who  attended  them  in  the  early 
stages,  and  seeing  no  further  syphiUtic  manifestations 
appear — (especially  after  intensive  arsenical  treatment 
—will  consider  themselves  definitely  cured,  and  take 
no  further  trouble,  with  subsequent  inability  to  beget 
healthy  children.  To  prove  that  these  fears  are  not 
exaggerated,  it  is  only  necessary  to  see,  at  a  hospital 
consultation,  the  carelessness  of  old  syphilitics,  the 
number  of  those  seen  for  the  first  time  and  treated 
properly  who  never  return  and  follow  no  treatment 
at  all  until  some  grave  symptom  appears.  In  an 
artisan  population,  and  still  more  in  a  rural  one,  it  is 
the  exception  to  see  syphihs  properly  treated  ;  mis- 
carriages, as  the  result  of  carelessly  tended  specific 
disease,  being  the  rule.  Medical  and  administrative 
propaganda  for  regular  and  prolonged  treatment 
have  still  much  to  do  before  erasing  this  culpable 
neghgence. 

SyphiUtics  recruited  into  the  Army  belong  for  the 
most  part  to  men  of  marrying  age,  or  who  have  been 
recently  married,  whose  procreative  faculties  are  in 
full  development,  and  who  are  destined  to  repopulate 
the  country.  From  a  national  point  of  view,  it  is 
of  very  little  importance  that  a  man  of  50  or  over 
should    contract    syphilis ;     his   procreative   work   is 


rm  SYPHILIS  AND   THE  AEMY 

done.  But  a  man  of  25  to  35  who  becomes  syphilitic 
has  forfeited  his  reproductive  power.  As  a  rule, 
a  man  who  develops  syphilis  between  35  and  45  is 
lost  for  reproduction  ;  the  period  during  which  he 
should  deny  himself  extending  to  an  ^ge  when  he  will 
have  no  desire,  or  when  his  posterity  would  be  alto- 
gether undesirable,  the  syphilitic  influence  -  being 
combined  with  that  of  age. 

Taking  into  account  the  proUficness  that  will  be 
necessary  to  bring  the  population  of  France  back  to 
its  indispensable  rate  on  the  one  hand,  and  the  varied 
ages  of  the  men  who  contract  syphilis  in  the  Army 
and  in  munition  works  on  the  other  hand,  there  is  no 
exaggeration  in  estimating  that  each  syphilitic  infec- 
tion of  a  mobiUsed  man  will  be  the  means  of  depriving 
France  of  at  least  one  soldier  and  one  mother  of  a 
family  during  the  decennial  period  1936  to  1945. 

Pautrier  expresses  the  same  idea  in  the  report, 
which  I  have  already  quoted,  on  the  organisation  of 
military  venereal  hospitals,  when  he  says,  after  having 
attempted  to  specify  the  exact  number  of  cases  of 
syphilis  in  the  Army  : 

"If  one  accepts  the  mean  figure  of  200,000,  which, 
while  hypothetical,  is  quite  possible,  and  attributes  to 
each  of  these  cases  the  production  of  two  miscarriages 
only,  it  is  evident  that  treponemic  infection  will  cost 
us  400,000  births,  i.e.  the  equivalent  of  two  classes. 

"  Thus,  the  word  '  national  peril '  is  not  too  strong." 

Surely  this  consideration  is  of  a  nature  to  justify 
the  most  energetic  measures,  even  the  most  drastic, 
to  prevent  the  propagation  of  syphihs. 

And  now,  when  on  all  sides  voices  are  being  raised 
in  denunciation  of  the  peril  of  depopulation  and 
demanding  the  repopulation  of  France,  when  leagues 
and  associations  are  being  proposed  with  the  object 
of  encouraging  large  famihes  and  protecting  the  life 
and  health  of  children,  is  it  not  urgent  to  dry  up  the 
source  of  such  a  waste  of  life  ? 


SYPHILIS  AS   A    NATIONAL   DANGER  535 

All  that  is  done  to  protect  the  Army  from  syphilis 
will  necessarily  rebound  favourably  on  the  population. 

In  the  follomng  chapters  I  shall  show  how,  from 
the  miUtary  side,  most  rational  measures  have  been 
taken  under  the  inspiration  of  Medical  Inspector 
General  Vaillard.  Mr.  Justin  Godart,  Under-Secretary 
of  State  of  the  Health  Service  of  the  War  Office,  in 
prescribing  these  measures  and  attacking  what  he 
also,  in  his  circular  of  January  5th,  1916,  has  caUed 
a  national  peril,  has  engaged  in  a  more  active  struggle 
against  syphilis  than  any  minister  has  ever  done 
before, and  by  the  instructions  issued  on  September25th, 
191 9,  has  responded  to  the  recommendations  of  the 
Academy  of  Medicine  at  the  meeting  of  June  13th, 
1916. 


CHAPTEK   IV 

SYMPTOMS  AND  DIAGNOSIS  OF  THE  SYPHILITIC  LESIONS 
MOST   COMMONLY   OBSERVED   IN   THE   ARMY 

This  book  is  not  a  treatise  on  syphilis,  nor  is  this  the 
place  to  give  a  complete  description  of  its  various 
manifestations.  Nevertheless,  it  seems  advisable  to 
refer,  with  necessary  details,  to  the  characteristics  and 
diagnostic  elements  of  the  main  syphihtic  lesions  likely 
to  be  observed  amongst  soldiers,  especially  primary 
and  secondary  symptoms.  Owing  to  their  frequency 
in  the  Army,  and  of  their  contagiousness,  the  military 
surgeon  ought  to  be  acquainted  with  their  diagnosis. 

SYPHILITIC   CHANCRE 

Developed  at  the  site  of  inoculation  of  the  syphihtic 
Tirus,  the  infective  chancre  in  soldiers  is  nearly  always 
found  on  the  genital  organs  or  in  their  immediate 
neighbourhood.  More  rarely,  it  is  situated  on  the 
tongue,  lips  or  tonsils,  but  it  is  then  the  result  of 
accidental  and  not  venereal  contamination.  It  is 
quite  exceptional  for  it  to  be  found  on  the  limbs. 

After  having  cited  the  symptoms  and  explained  the 
diagnosis  of  syphihtic  chancre  on  the  genital  organs,  I 
shall  give  a  description  of  the  extra-genital  locahsations 
of  chancre  most  frequently  observed. 

Period  of  Incubation  of  the  Chancre.  Its  Duration. 
— Syphihtic  chancre — ^this  is  a  characteristic  of  the 
utmost  importance  from  the  point  of  view  of  its  diag- 

536 


SYMPTOMS   AND  DIAGNOSIS  537 

nosis  from  simple  chancre — does  not  appear  imme- 
diately after  the  infective  contact,  but  is  separated  from 
it  by  a  very  clearly  defined  period  of  incubation.  The 
duration  of  this  period  is  from  25  to  30  days,  accord- 
ing to  proved  clinical  observations,  the  confirmation 
of  the  patients  and  those  who  have  infected  them, 
and  the  experimental  inoculations  made  on  man  ; 
it  is  rarely  less  than  14  to  17  days  ;  but  may 
extend  to  40  days,  and  very  exceptionally  even 
beyond  that  period. 

Owing  to  the  conditions  of  military  service,  espe- 
cially at  the  front,  it  is  often  possible  for  the  man 
to  fix  the  date  of  the  infective  intercourse,  when  he 
is  wilHng  to  do  so.  Thus,  by  means  of  careful  ques- 
tions, and  having  regard  to  the  intelligence  of  the 
man  and  the  conditions  which  may  influence  the 
veracity  of  his  statements,  it  is  possible  to  make  a 
presumptive  diagnosis  from  the  duration  of  the 
incubation.  On  the  other  hand,  comparison  of  the 
age  of  a  chancre  with  the  dates  of  leave  may  some- 
times show  the  inexactitude  of  his  statements. 

In  order  to  make  use,  for  diagnostic  purposes,  of  the 
information  supplied  by  the  soldier  suffering  from 
a  chancre,  it  is  necessary  to  weigh  his  statements  very 
carefully,  and  check  them  in  every  way  possible. 

Causes  of  Localisation  of  the  Chancre. — Syphihtic 
inoculation  takes  place  through  a  solution  in  con- 
tinuity of  the  integument,  a  traumatic  excoriation 
at  the  moment  of  infective  intercourse,  a  lesion  from 
scratching  induced  by  the  presence  of  pediculosis 
pubis  or  scabies,  etc.  At  the  moment  the  chancre 
appears  this  lesion  has  nearly  always  disappeared, 
leaving  no  trace,  and  often  even  no  recollection  of 
it.  The  concomitant  lesions  of  itch  or  the  presence 
of  crab-lice  may  still  be  in  existence  and  explain 
certain  particularities  of  the  syphilitic  infection  :  this 
is  why  chancres  following  itch  are  often  multiple, 
and  sometimes  very  numerous,  the  points  of  entry 


538  SYPHILIS  AND   THE  ARMY 

made  by  the  acarus  being  also  multiple.  This  also 
explains  why  chancres  which  have  appeared  on  persons 
affected  with  pediculi  are  frequently  situated  on 
excoriations  due  to  scratching  in  the  pubic  region, 
inside  the  thighs  and  scrotum,  regions  on  which  a 
syphihtic  chancre  is  locaUsed  more  rarely  than  on  the 
penis. 

Commencement  of  the  Chancre. — A  chancre  develops 
in  healthy  skin  ;  it  commences  as  a  rounded  papule, 
bleeding  easily,  of  firm  consistency,  with  a  slight 
erosion  in  the  centre  ;  but  at  this  stage  it  has  no 
pathognomonic  characteristic.  It  must  be  added, 
further,  that  the  chancre  is  rarely  observed  by  the 
medical  man  at  this  stage,  and  indeed  can  only  be 
noticed  in  patients  who  are  scrupulously  careful  or 
nervous,  who  consult  a  doctor  the  moment  there  is 
anything  abnormal  on  their  genital  organs. 

During  the  following  days  the  lesion  progresses, 
becomes  larger  and  more  defined,  the  induration 
increases,  and  the  ulceration  extends. 

Stage  of  Maturity. — When  the  syphilitic  chancre 
has  developed  it  is  possible  to  define  it  as  an  ulcera- 
tion situated  upon  a  hard  base.  I  ought  rather  to 
say  ex-ulceration,  for  the  loss  of  substance  is  very  often 
superficial. 

Smooth,  with  a  regular  surface,  presenting  neither 
depressions  nor  projections,  such  as  are  seen  on  the 
irregular  base  of  simple  chancre,  the  ex-ulceration  is 
ordinarily  on  a  level  with  the  neighbouring  skin, 
sometimes  it  projects  above  it  ;  occasionally  it  is 
depressed  and  saucer-shaped  ;  more  rarely  still,  it  is 
excavated. 

The  surface  of  this  ulceration  is  generally  glazed 
of  a  special  red  colour,  which  has  been  compared  by 
all  classical  writers  to  that  of  muscular  tissue  ;  if 
observed  carefully  under  a  magnifying  glass,  it  is 
found  that  it  is  not  uniform,  but  very  finely  granulated, 
sprinkled  with  Uttle  specks  of  deeper  red,  which  are 


SYMPTOMS  AND  DIAGNOSIS  539 

nothing  but  fine  vascular  dilatations.  Some  chancres 
are  of  a  different  colour  ;  they  are  covered  by  a  greyish 
layer,  almost  diphtheroid,  which,  although  not  thick, 
is  very  adherent.  This  coloration  often  does  not 
cover  the  whole  surface  of  the  chancre,  but  forms  a 
concentric  circle  around  its  border  ;  -the  result  is  a 
pecuhar  appearance,  which  goes  by  the  description 
chancre  in  rosette. 

SyphiUtic  chancre  of  the  genital  organs  does  not 
suppurate  ;  here  it  differs  completely  from  simple 
chancre  :  all  it  does  is  to  exude  a  very  small  quantity 
of  serous  fluid,  which  keeps  up  a  sKght  moisture  on 
the  surface  and  aids  in  giving  it  its  glazed  appearance. 
J.  Nicolas  *  has  called  attention  to  the  facihty  with 
which  this  discharge  can  be  induced.  It  is  only 
necessary,  when  the  chancre  has  come  to  a  head,  to 
execute  sHght  friction  with  a  hard  body  such  as  a 
platinum  spatula  or  vaccination  needle,  to  see  the 
surface  covered  over  by  a  clear,  transparent  serum  : 
this  discharge,  if  the  friction  is  continued,  becomes 
abundant  enough  to  be  collected  with  the  spatula  or 
needle. 

This  characteristic  is  very  important  from  the 
point  of  view  of  diagnosis  of  the  chancre,  because  it 
is  in  this  exudation  resulting  from  serous  drainage  of 
the  superficial  layers  of  the  chancre  that  it  is  most 
easy  to  detect  the  presence  of  the  spirochaete.  I  shall 
refer  again  later  to  this  point,  when  discussing  the 
bacteriological  diagnosis  of  chancre. 

On  the  skin,  or  more  accurately  in  the  regions 
where  the  nature  of  the  integument  does  not  allow 
of  a  certain  degree  of  constant  moisture,  the  secretion 
of  the  chancre  forms  into  more  or  less  thick  scabs 
{scahous  chancre)  ;  but  these  scabs  always  remain 
dry,  and  no  layer  of  pus  is  found  below  them,  such 
as  happens  with  simple  chancre  or  with  ecthyma. 

*  J.  Nicolas,  "  Selmudinn  and  Hoffmann's  Spirochaeta  Pallida  and 
Syphilis"  [Lyon  medical,  October  1st,  1905,  p.  497). 


540  SYPHILIS   AXD   THE  ABJIY 

Syphilitic  chancre  is  nearly  always  of  regular 
formation,  extremely  regular,  geometrical,  roimded  or 
oval.  In  certain  regions,  like  the  anus,  it  may  take 
on  a  fissure-lilve  form,  or  be  disposed  like  the  Jeai-es 
of  a  book. 

The  dimensions  are  variable.  It  may  remain  small 
through  its  whole  evolution,  in  a  state  of  dwarf  chancre, 
resembhng  a  herpetic  erosion.  The  average  size  is 
about  the  size  of  a  sixpence.  It  is  altogether  excep- 
tional, especially  on  the  genital  organs,  for  it  to 
attain  the  size  of  a  shilhng  or  over  :  it  is  only  on  the 
body  that  larger  dimensions  may  be  attained,  meriting 
the  name  of  giant  chancre. 

The  ulceration  of  a  syphiUtic  chancre  rests  upon  an 
indurated  base  ;  this  is  the  main  characteristic,  which 
is  of  great  importance  from  a  diagnostic  point  of 
view,  and  has  gained  for  it  the  name  of  indurated 
chancre.  As  a  matter  of  fact,  it  is  altogether  excep- 
tional for  the  induration  to  be  absent,  especially'  in 
man  ;   but  it  varies  in  intensity.  ^ 

In  order  to  appreciate  this  clearly,  it  is  necessary  to 
proceed  methodically  :  the  thumb  and  index  finger, 
covered  by  a  rubber  finger-stall,  or  protected  by 
lint,*  and  opposite  to  each  other,  are  placed  one  at 
each  of  the  extremities  of  one  of  the  diameters  of  the 
ulceration  and  at  a  centimetre  or  demi-cen  timet  re 
outside  it  :  approaching  one  to  the  other,  the  base 
of  the  chancre  is  slightly  raised  by  means  of  moderate 

*  It  cannot  be  urged  too  strongly  on  medical  men  to  take  pre- 
cautions, when  called  upon  to  examine  patients  suffering  from 
ulcerous  lesions  of  the  genital  organs  or  other  regions.  They  should, 
first  of  all,  see  that  there  is  neither  sore  nor  excoriation  on  any  of 
the  parts  likely  to  come  in  contact  with  the  suppui-ating  lesions  of 
their  patients,  and,  if  they  have  any,  the?e  should  be  covered  up 
%vith  plaster. 

At  a  consultation,  at  which  a  certain  number  of  venereal  patients 
are  present,  it  is  a  good  thing  to  have  rubber  finger-stalls  at  hand, 
which  should  be  put  on  before  manipulating  the  chancres. 

A  compress,  or  even  a  thin  tuft  of  wadding,  can  be  used  instead 
of  gloves. 

After  touching  an  ulceration,  the  do<tor  should  wash  his  hand* 


SYMPTOMS  AND   DIAGNOSIS  541 

pressure  ;  it  is  then  easy  to  feel,  between  the  two 
fingers,  the  existence  of  a  firm  plaque  of  regular  con- 
sistency, but  varying  in  one  case  from  another.  It 
is  more  like  the  sensation  that  would  be  given  by  a 
sheet  of  thick  paper  or  parchment  (papyraceous 
induration),  rather  than  that  of  cartilage,  or  even 
of  a  piece  of  wood  (ligneous  induration).  There  is 
always  a  certain  elasticity  in  this  induration.  Unless 
it  is  very  large,  it  can  be  distorted  shghtly  by  pressure. 
and  the  surface  of  the  chancre,  from  being  level, 
becomes  sHghtly  convex,  like  a  sheet  of  flexible  card- 
board. 

The  degree  of  induration  is  often,  but  not  always, 
in  relation  to  the  dimensions  of  the  chancre  :  dwarf 
chancres  may  have  a  very  indurated  base,  voluminous 
chancres  may  rest  upon  a  papyraceous  induration. 

The  induration  always  extends  beyond  the  limits  of 
the  ulceration.  When  it  has  reached  a  certain  degree 
it  forms,  as  it  were,  a  pastille  wdth  an  ulcerated  centre. 

The  induration  of  some  chancres  is  obvious  :  situ- 
ated upon  convex  or  cylindrical  parts,  they  do  not 
conform  to  the  contour,  but  their  two  extremities 
project  from  the  adjacent  tissues,  thus  proving  that 
their  base  is  hard  and  unyielding.  The  induration 
gives  rise  to  a  particularly  curious  phenomenon  in 
chancres  occupying  the  internal  surface  of  the  prepuce 
near  its  insertion  :  if  the  prepuce  is  retracted,  at  the 
moment  its  folds  reach  the  lower  border  of  the  chancre. 


with  soap  and  water,  or,  simpler  still,  dip  the  fingers  into  alcohol, 
as  they  may  have  been  soiled  by  the  secretions. 

Further,  I  cannot  recommend  too  strongly  that  the  genital  organs 
of  a  patient  should  never  be  examined  without  having  exposed 
the  entire  region,  and  ordered  the  patient  to  remove  his  hands  : 
these,  which  have  often  touched  the  dressings  or  ulcerations,  may  be 
soiled  by  contagious  pus,  and  the  doctor  risks  contamination  from 
the  scratch  of  a  finger-nail,  should  the  patient  move  suddenly. 

Finally,  the  medical  man  shoiild  always  see  that  the  dressings 
which  have  been  in  contact  with  the  ulcerations  arc  not,  under  any 
pretext,  placed  on  a  chair  or  on  the  floor,  but  are  put  by  the  patient 
himself  into  a  receptacle,  or  on  a  paper  to  be  burned. 


542  SYPHILIS   AND   THE  ARMY 

it  is  lifted  abruptly  on  to  the  corona  of  the  glans, 
executing  exactly  the  same  movement  as  the  tarsal 
cartilage  does  during  the  e version  of  the  eyelid.  In 
these  cases,  it  is  almost  unnecessary  to  feel  the  indura- 
tion with  the  fingers  :  it  reveals  itself  to  sight,  and 
cannot  be  mistaken  for  anything  else. 

Besides  the  induration,  the  base  of  a  syphilitic  chancre 
may  be  the  seat  of  more  or  less  pronounced  infiltration 
and  of  tumefaction,  which  cause  considerable  deformity. 
Thus  certain  chancres  of  the  prepuce  produce  very 
marked  phimosis,  with  enormous  increase  in  the  volume 
of  the  prepuce,  giving  rise  to  distortion,  described  as 
"  bell-clapper  penis,"  which  is  almost  pathognomic  of 
syphilitic  chancre.  Through  the  oedematous  and 
tumified  prepuce,  it  is  possible  to  feel  one  or  more 
indurated  plaques,  indicative  of  chancres  of  the 
prepuce  concealed  by  the  intensity  of  the  phimosis. 

Contrary  to  simple  chancre,  the  syphilitic  chancre  is 
painless,  spontaneously,  under  the  influence  of  pressure, 
or  of  exterior  contact.  Nevertheless,  chancres  situated 
on  the  preputial  orifice,  or  on  the  urinary  meatus, 
are  painful  during  micturition.  External  irritation 
may  occasionally  render  chancres  painful,  no  matter 
where  situated,  by  inducing  inflammation. 

Habitual  Unicity  of  Syphilitic  Chancre  ;  its  Frequent 
Multiplicity. — Although  a  syphilitic  chancre  is  generally 
single,  this  is  not  the  case  as  much  as  is  currently 
believed  from  the  schedule  of  Ricord.  It  is  multiple 
in  one  case  out  of  four  ;  but  it  is  rare  to  observe  more 
than  three  or  four  in  the  same  subject.  Multiple 
chancres  may  be  situated  on  the  same  region,  or  on 
different  parts  of  the  body  :  in  this  way,  one  may  see  a 
chancre  of  the  genital  organs  and  one  of  the  anus  or 
cephalic  extremity  developing  simultaneously,  accord- 
ing to  the  hazards  of  inoculation. 

Results  of  the  Inoculation  of  Syphilitic  Chancre  on  the 
Bearer  of  the  Chancre. — It  has  long  been  considered  an 
important  characteristic  of  syphilitic  chancre  that  it 


SYMPTOMS   AND   DIAGNOSIS  543 

was  impossible  for  it  to  inoculate  its  bearer.  The 
researches  of  Queyrat  have  recently  shown  that,  under 
this  form,  the  proposition  was  not  correct,  and  that,  at 
any  rate  during  the  first  weeks  of  its  evolution,  it  was 
possible  to  obtain  a  lesion  of  a  chancrous  nature  at 
the  point  of  an  inoculation  ;  this  lesion  becomes  more 
and  more  attenuated,  in  proportion  to  the  age  of  the 
chancre,  but  is  always  characterised  by  more  or  less 
pronounced  induration,  with  or  without  ulceration. 

The  old  opinion,  therefore,  cannot  be  regarded  as 
strictly  accurate.  It  is  none  the  l^ss  true  that  the 
syphilitic  chancre  differs  from  simple  chancre,  from  the 
point  of  view  of  inoculation.  Whereas  the  latter,  up 
to  an  advanced  period  of  its  evolution,  reproduces  by 
inoculation  a  lesion  at  the  end  of  about  forty-eight 
hours,  characterised  by  a  pustule  and  leading  on  the 
fourth  day  to  the  development  of  a  deep  ulceration 
with  detached  borders,  inoculation  of  the  secretion  or 
tissue  of  a  syphilitic  chancre  produces  nothing  in  this 
time,  and  gives  rise,  after  ten  to  fifteen  days,  to  a  lesion 
characterised  by  an  infiltrative  papule  which  may 
afterwards  become  ulcerated,  but  never  becomes  an 
ulcer  with  detached  borders.  In  short,  inoculation 
of  the  infecting  chancre  never  gives  rise  to  the  inocula- 
tion lesion  made  known  by  Hunter  and  Ricord  ;  the 
law  of  Bassereau  remains  always  true. 

Evolution  of  the  Syphilitic  Chancre. — ^When  left  to 
itself,  the  syphilitic  chancre  lasts  about  four  weeks  ; 
parchment-like  chancres  evolve  more  rapidly,  while 
extensive  ones  with  much  induration  last  longer. 
Treatment,  especially  with  arsenobenzol,  hastens  the 
cicatrisation  of  the  chancre. 

Healing  is  evidenced  by  diminished  induration ; 
the  diphtheroid  membrane,  if  it  existed,  falls  ;  the 
surface  becomes  less  red,  granulates,  and  heals  up  ; 
the  ulcer  gradually  contracts. 

After  healing,  a  level,  soft  cicatrix  remains,  which  is 
pigmented  for  a  long  time  and  often  retains  a  certain 


544  SYPHILIS  AND   THE  ARMY 

degree  of  infiltration  and  induration  appreciable  to 
careful  palpation  for  several  weeks,  especially  if  the 
chancre  has  not  been  treated  with  arsenobenzol. 

Effect  of  the  Chancre  on  the  Vessels  and  Lymphatic 
Glands  {Lymphitis  and  Adenopathy). — The  syphilitic 
chancre  rapidly  implicates  the  vessels  and  lymphatic 
glands,  more  than  any  other  cutaneous  or  mucous 
lesion. 

A  few  hours  after  its  appearance,  it  is  frequently 
accompanied  by  lymphitis  ;  this  is  specially  appreciable 
with  chancres  of  the  prepuce  and  glans,  on  the  dorsal 
surface  of  the  penis,  in  the  form  of  one  or  two  slightly 
moniliform  or  smooth  indurated  cords,  which  have 
often  been  taken  for  phlebitis.  This  lymphitis  persists 
for  the  duration  of  the  chancre,  and  disappears  at  the 
moment  of  its  cicatrisation. 

The  lymphatic  glands  corresponding  to  the  region 
of  the  chancre  are  also  affected  at  an  early  date.  The 
satellite  adenopathy  of  the  chancre,  which,  at  first  single, 
rapidly  becomes  multiglandular ;  hard,  enlarged, 
isolated  from  each  other,  the  glands  are  painless  on 
pressure,  and  movement.  Sometimes,  however,  under 
the  influence  of  traumatic  irritation  and  secondary 
infection,  they  may  become  inflamed,  increase  still 
further  in  volume,  become  surrounded  by  periadenitis,, 
and  painful^  but  they  practically  never  suppurate. 

According  to  Ricord,  a  more  voluminous  gland  is 
often  seen  in  the  midst  of  smaller  ones,  which  is  some- 
times harder  and  corresponds,  according  to  classical 
teaching,  to  the  lymphatics  coming  directly  from  the 
chancre. 

The  adenopathy  of  a  syphilitic  chancre,  however,  is 
not  always  in  direct  anatomical  relationship  with  the 
seat  of  the  chancre  itself  ;  it  is  not  unusual,  with  a 
chancre  clearly  on  one  side  of  the  glans  or  prepuce, 
to  see  adenopathy  develop  in  both  groins  ;  nor, 
with  a  chancre  similarly  situated,  to  find  the  lym- 
phatic glands  on  the  same  side  immune,  whereas  those 


SYMPTOMS  AND  DIAGNOSIS  545 

on  the  opposite  one  are  the  seat  of  very  pronounced 
adenopathy. 

It  is  well  to  noi^e  that,  in  exceptional  cases,  the 
regional  adenopathy  is  absent  during  the  whole  of  the 
evolution  of  the  chancre. 

The  adenopathy  persists  after  the  chancre  for 
some  weeks,  often  for  months  ;  it  disappears  more 
rapidly  with  patients  who  have  been  treated  with, 
arsenical  preparations. 

Diagnostic  Elements  of  Syphilitic  Chancre 

The  diagnosis  of  syphilitic  chancre  depends  on  four 
factors  :  the  objective  signs  ;  its  evolution ;  signs 
drawn  from  the  patient's  antecedents  and  the  appear- 
ance of  symptoms  of  secondary  syphilis  ;  lastly  on 
laboratory  researches. 

Diagnostic  Importance  of  the  Objective  Signs 

Of  all  the  objective  signs  already  described,  the  most 
important  are  :  the  slight  depth  of  the  ulceration  ; 
absence  of  detachment  of  the  borders,  this  sign  enabling 
one  to  recognise  that  it  is  not  a  question  of  simple 
chancre  ;    induration  of  the  base. 

This  last  characteristic  is  of  the  utmost  importance  : 
a  clearly  defined  induration,  limited  to  the  base  of  the 
syphilitic  chancre,  is  almost  a  pathognomonic  sign.  But 
it  is  also  necessary  that  the  mduration  belongs  to  the 
lesion  it  accompanies,  and  is  not  superimposed. 

It  often  happens  that  a  simple  ulceration,  an  ex- 
coriation occurring  during  coitus,  herpetic  ulcera- 
tion, etc.,  has  been  subjected  to  irritant  treatment, 
covered  with  unsuitable  remedies,  and  has  become  sur- 
rounded by  an  inflammatory  inflammation  simulating 
the  characteristics  of  basal  induration. 

Various  remedies,  sometimes  the  most  improbable 
ones,  may  cause  this  condition.  It  is  frequently 
noticed  after  the  application  of  ashes  from  a  pipe,  a 


546  SYPHILIS  AND  THE   ARMY 

very  favourite  remedy  among  the  people.  Some 
patients,  haunted  by  the  fear  of  syphilis,  directly  they 
notice  an  ulceration  of  the  genital  organs,  hasten  to 
heap  upon  it  all  the  antiseptic  liquids  they  have  to 
hand  :  tincture  of  iodine,  concentrated  carbolic  acid, 
permanganate  of  potash,  peroxide  of  hydrogen,  sub- 
limate, nitrate  of  silver,  etc.,  and  to  cover  it  with  all  the 
powders  of  the  pharmacopoeia.  The  result  is  that, 
when  they  consult  a  doctor,  it  is  impossible  for  him  to 
diagnose  the  cause  of  the  induration,  which  might 
equally  well  belong  to  the  lesion  itself,  or  be  the  con- 
sequence of  unsuitable  treatment. 

A  much  more  frequent  cause  of  induration  is  the  use 
of  calomel  on  ulcerations  of  the  genital  organs,  either 
in  the  form  of  powder  or  of  ointment.  These  two 
remedies  have  for  long  been  advised  by  famous  syphilo- 
logists  in  the  treatment  of  syphilitic  chancre  :  experi- 
ence has  long  shown,  however,  that  they  are  of  no 
special  value,  and  should  be  abandoned.  But,  above 
all,  they  must  never,  under  any  pretext  whatever,  be 
applied  to  an  ulceration  not  yet  properly  diagnosed. 

Under  these  conditions,  calomel,  either  as  powder  or 
ointment,  must  be  prohibited  in  the  treatment  of  ulcera- 
tions of  the  genital  organs. 

Inflammatory  infiltration  differs  from  true  induration 
by  having  less  firmness,  less  regularity,  and  less  clearly 
defined  limitation.  When  the  infiltrated  base  of  a 
simple  ulceration  is  pressed  between  two  fingers,  this 
base  can  be  depressed  and  modelled,  so  to  speak, 
instead  of  becoming  tense,  and  raised  with  a  certain 
convexity,  like  the  syphilitic  chancre  ;  when  pressed  on 
the  two  extremities  of  one  of  its  diameters,  its  surface 
seems  to  double  up  under  the  fingers.  If  doubt  still 
persists  after  examination  and  the  other  diagnostic 
elements  are  uncertain,  the  patient  should  be  told  to 
apply  a  dressing  of  boiled  water  for  two  or  three  days 
to  the  exclusion  of  any  other  remedy  :  an  inflammatory 
infiltration  generally  becomes  modified  or  disappears 


SYMPTOMS   AND  DIAGNOSIS  54:7 

at  the  end  of  this  time,  whereas  a  syphilitic  chancre 
persists. 

Diagnostic  Value  of  the  Signs  drawn  from  the  Evolution 
of  the  Chancre 

I  have  already  indicated  (see  page  34)  the 
existence  and  duration  of  the  incubation  period  of 
syphilis.  It  is  necessary  to  revert  to  this  here,  in  order 
to  show  that,  in  certain  cases,  this  factor  is  of  great 
importance  in  diagnosis.  A  simple  chancre  has  no 
incubation,  or  at  least  the  period  is  very  short,  not 
exceeding  two  or  three  days,-  so  that,  in  every  case 
where  an  ulceration  develops  more  than  four  or  five 
days  after  the  last  coitus,  the  diagnosis  of  simple 
chancre  is  untenable. 

On  the  other  hand,  the  fact  of  recent  coitus  is  not 
sufficient  to  eliminate  the  possibility  of  syphilitic 
chancre,  contamination  possibly  extending  to'  an  earlier 
one.  It  is  only  in  the  case  where,  the  patient's  state- 
ments appearing  to  be  perfectly  truthful,  no  possibility 
of  sjrphiUtic  infection  can  be  found  for  several  months, 
apart  from  the  recent  coitus,  that,  relying  on  these 
statements  alone,  one  might  admit  with  certainty  the 
existence  of  a  simple  chancre. 

Deductions  drawn  from  the  statements  of  the  patient, 
as  I  have  already  remarked,  have  but  a  relative  value, 
depending  on  his  truthfulness  and  intelligence. 

Signs  drawn  from  the  Patient's  Antecedents,  or  from  the 
Appearance  of  Symptoms  of  Secondary  Syphilis 

Syphilis  only  recurs  exceptionally ;  the  certain 
knowledge  of  previous  syphiHs  should  put  one  on  one's 
guard  against  the  diagnosis  of  syphilitic  chancre.  To 
tell  the  truth,  it  is  a  dangerous  postulate  to  reject  this 
diagnosis,  for  the  sole  reason  that  the  patient  states  he 
has  previously  had  syphilis  or  a  chancre.  In  the  first 
place,  the  patient's  statements  may  be  incorrect,  con- 


548  SYPHILIS  AND  THE  ARMY 

fusion  existing  in  his  mind  between  all  venereal  dis- 
eases :  what  he  had  previously  called  syphilis  may  have 
been  nothing  but  gonorrhoea,  an  error  which  can  be 
overcome  by  making  the  patient  specify  the  symptoms 
he  has  experienced. 

In  the  second  place,  the  diagnosis  of  the  first  affec- 
tion may  have  been  incorrectly  made  by  the  prac- 
titioner consulted  at  that  time,  a  mistake  more  difficult 
to  eliminate. 

Finally,  rare  as  they  are,  syphiUtic  re-infections 
do  take  place,  contrary  to  the  opinion  of  Ricord  and 
Alfred  Fournier;  but  these  must  not  be  admitted 
unless  the  diagnosis  of  the  first  attack,  and  that  of 
the  second,  are  based  on  undoubted  facts. 

Thus,  if  in  a  patient  the  antecedents  of  former 
acquired  syphihs  seem  certain,  it  will  be  necessary, 
before  diagnosing  infective  chancre,  to  be  doubly 
sure  and  to  have  this  confirmed  by  the  most  accurate 
methods — ^I  am  not  now  speaking  of  hereditary 
syphilis,  or  at  least  of  hereditary  antecedents  of 
syphihs,  for  it  is  demonstrated  by  numerous  observa- 
tions that  the  descendants  of  syphiUtics  may  contract 
the  disease  like  others. 

The  development  of  secondary  syphiUtic  affections 
appears,  under  normal  conditions,  after  an  ulceration 
which  has  presented  more  or  less  marked  characteris- 
tics of  syphiUtic  chancre,  and  may  help  in  the  diagnosis 
of  the  latter.  We  shall  see,  as  a  matter  of  fact,  after 
having  recourse  to  all  methods  of  examination,  that 
a  doubt  may  still  persist  as  to  the  nature  of  a  genital 
ulceration  :  this  can  only  be  determined  by  the 
appearance  of  roseola  or  of  mucous  plaques.  But,  as 
secondary  symptoms  only  develop  six  weeks  after  the 
appearance  of  the  chancre,  this  is  the  slowest  method 
to  which  one  can  have  recourse,  a  final  one,  a  make- 
shift one  for  which  one  would  only  decide  to  wait 
under  very  exceptional  and  speciaUy  embarrassing 
circumstances. 


SYMPTOMS   AND   DIAGNOSIS  549 

Indications  supplied  by  Laboratory  Researches 

Experimental  bacteriological  researches,  since  1905, 
have  brought  an  aid  to  syphihtic  diagnosis,  which 
cannot  to-day  be  ignored  in  doubtful  cases. 

Without  discussing  the  laboratory  inoculations  of 
animals,  which  in  certain  limited  cases  may  render 
first-class  help,  but  are  totally  impracticable  in  the 
laboratories  improvised  in  sanitary  centres,  there  are 
two  methods  which  can  be  utihsed  for  general  syphihtic 
diagnosis  :  research  for  the  parasite  of  syphiUs  and 
complement-fixation . 

Research  for  the  Parasite  of  Syphilis. — ^The  spiro- 
chsete  of  Schaudinn  and  Hoffmann,  to-day  generally 
called  Treponema  pallidum  in  France,  if  definitely 
found,  is  sufficient  to  classify  as  syphihtic  the  lesion 
in  which  it  has  been  demonstrated,  and  if  this  lesion 
presents  the  objecti^^e  or  evolutionary  characteristics 
of  a  chancre,  it  can  be  stated  definitely  that  it  is  a 
syphihtic  chancre. 

It  is  easy  to  look  for  this  parasite  :  it  can  be  done 
with  any  microscope,  with  the  aid  of  staining  methods, 
if  the  microscope  used  is  only  an  ordinary  one,  or 
by  direct  examination  of  the  preparations  on  a  dark 
field,  if  the  observer  possesses  a  so-called  ultra- 
microscope. 

The  first  rule  to  be  observed,  in  searching  for  this 
parasite,  is  to  examine  the  preparations  in  which  it 
is  possible  to  find  it,  if  it  is  present. 

Indeed,  infective  suppurating  chancres  supply  secre- 
tions full  of  microbes  of  all  kinds,  in  the  midst  of 
which  the  spirochsete  is  unperceived,  or  confused  with 
the  innumerable  series  of  non-pathogenic  spiriUae. 

Further,  the  various  antiseptic  remedies  used 
wrongly  or  rightly  in  the  treatment  of  ulcerations  of 
the  genital  organs  have  the  effect  of  destroying  this 
ver}^  vulnerable  parasite,  at  any  rate  in  the  super- 
ficial lavers  of  the  ulceration. 


550  SYPHILIS  AND   THE   ARMY 

Hence,  if  the  treponema  is  to  be  searched  for  in 
an  ulcer  of  the  genital  organs,  whether  suppurative, 
infective,  or  treated  by  some  antiseptic,  it  is  necessary 
to  put  a  dressing  of  boiled  water  only  on  the  ulcer 
for  at  least  forty-eight  hours,  which  should  be  kept 
on  permanently  and  renewed  twice  daily,  and  bathe 
it  also  with  pure  boiled  water;  every  antiseptic,  no 
matter  how  weak,  being  absolutely  excluded. 

Chancres  covered  with  a  diphtheroid  layer  should 
also  be  subjected  for  forty-eight  hours  to  dressings 
of  boiled  water. 

To  collect  the  material  for  examination  :  the  best 
method  consists  in  applying  superficial  friction  to  the 
surface  of  the  ulcer,  by  means  of  a  hard  body,  a 
platinum  spatula  or  vaccination  needle,  which  should 
be  first  steriUsed  by  heating  in  a  flame.  The  ulcer 
will  soon  be  covered  bv  an  abundant  serum. 

Nevertheless,  in  chancres  of  long  standing  this 
serum  is  only  obtained  with  difficulty,  and  not  in 
adequate  quantities  for  examination  purposes  ;  it  is 
necessary  to  scarify  the  surface  lightly  and  collect 
the  mixture  of  blood  and  serum  which  flows  from  the 
scarifications. 

The  fluid  is  spread  on  a  shde  in  a  thin  layer.  If  the 
examination  is  to  be  made  with  an  ultra-microscope 
it  is  simply  covered  with  a  cover-glass  and  examined 
direct.  In  the  absence  of  the  ultra-microscope,-  re- 
course must  be  had  to  staining  methods. 

The  classical  method  of  microscopic  examination  of 
the  spirochsete  is  that  of  Giemsa,  which  has  the 
advantage  of  supplying  a  fairly  characteristic  coloured 
reaction.  This  method  consists  in  diluting  Giemsa's 
solution  (which  is  composed  of  3  grammes  of  Azur  II 
Eosin,  08  gramme  of  Azur  II  in  250  grammes  of 
glycerine,  evaporated  to  dryness,  and  added  to  250 
grammes  of  Methyl  Alcohol  in  the  proportion  of  1  drop 
to  1  cubic  centimetre  of  distilled  water.  The  pre- 
paration is  dried  in  air,  then  fixed  for  ten  minutes 


SYMPTOMS   AND  DIAGNOSIS  551 

in  absolute  alcohol,  or  it  may  be  fixed,  before  drying. 
by  osmic  acid  vapour  ;  it  is  then  immersed  for  one  or 
more  hours  in  the  colouring  solution.  For  a  rapid 
diagnosis,  the  same  solution  may  be  used,  rather 
more  concentrated  and  with,  or  without,  the  addition 
of  1%  glycerine  ;  staining  is  then  produced  by  heating 
until  steam  is  produced,  renewing  the  fluid  3  to  5 
times  ;  staining  is  complete  as  soon  as  the  blood- 
corpuscles  appear  vividly  pink  under  a  low  magni- 
fication. 

With  Giemsa's  method  of  preparation,  the  microbes 
are  coloured  bluish-violet,  as  well  as  the  non-patho- 
genic spirilla  and  the  cell  nuclei,  the  blood-corpuscles 
are  pink,  and  the  treponema  pallidum  reddish-pink. 
It  is  seen  best  in  the  neighbourhood  of  the  blood- 
corpuscles. 

In  default  of  Giemsa's  *  reagent,  one  can  have 
recourse  to  silver  staining,  already  made  by  Ravaut 
with  largine,  and  which  Fontana  carries  out  in  the 
following  manner :  the  preparation  is  fixed  and 
decolorised,  by  means  of  an  aqueous  solution  of  acetic 
acid  (1%)  and  of  formol  (2%),  then  heated  for  30 
seconds  in  a  5%  solution  of  tannic  acid,  and,  after 
washing,  treated  with  an  ammoniacal  solution  of 
5%  nitrate  of  silver,  also  for  30  seconds. 

The  Chinese  ink  method  has  been  employed  more 
abroad  than  in  France.  Owing  to  the  facility  of  its 
use,  and  in  default  of  an  ultra-microscope,  it  may 
be  of  service  in  army  laboratories.  It  consists  in  the 
employment  of  a  dilution  of  Chinese  ink,  which  forms 
a  dark  ground  on  which  the  treponema s  appear  colour- 
less. 

As  a  general  rule,  however,  the  favourite  method 
of  seeking  for  the  spirochsete  is  examination  on  a 
dark  ground,  called  the  ultra-microscope  method.  I 
think  it  has  been  adopted  by  all  syphilologists,  on 

*  Giemsa's  solution,  being  the  monopoly  of  a  German  firm  before 
the  present  war,  is  now  being  prepared  by  French  manufacturers. 


552  SYPHILIS   AND   THE   ARMY 

account  of  its  rapidity  and  simplicity ;  but  it  neces- 
sitates special  apparatus,  which  is  not  provided  in 
many  of  the  army  laboratories  and  medical  centres. 
With  the  illumination  obtained  from  this  apparatus, 
the  ground-work  of  the  preparation  remains  dark, 
whereas  the  corpuscles  immersed  therein  are  vividly 
illuminated  and  show  up  very  clearly. 

The  examination  is  made  either  with  a  dry  or  an 
oil-immersion  lens,  in  fresh  preparations,  in  which 
the  spirochsetes  are  seen  living,  moving  from  place  to 
place,  thus  facilitating  research  and  their  identification. 

In  fixed  and  stained  preparations,  the  spirochaete 
appears  as  an  extremely  fine  thread,  tapering  at  its 
two  extremities  and  twisted  into  a  spiral  like  a  cork- 
screw, with  many  turns  (6  to  12  on  an  average). 
The  turns  of  the  spiral  are  narrow,  regular,  and  deep. 
The  total  length  of  the  parasite  is  from  6  to  20  /it  ; 
its  width  from  |  to  J  /^  ;  on  an  average  its  length 
slightly  exceeds  the  diameter  of  a  blood  corpuscle. 

Examined  with  the  ultra-microscope,  it  is  mobile. 
It  can  move  round  its  longitudinal  axis,  advancing 
or  retreating  by  jerks  and  in  a  straight  line  ;  or,  while 
remaining  in  the  same  place,  it  performs  undulations 
or  makes  movements  of  flexion  and  torsion  ;  some- 
times its  two  extremities  unite  so  as  to  form  a  circle. 

The  Treponema  palUdum  is  distinguished  from 
other  spirilla  by  its  regularity,  the  multipUcity  and 
permanence  of  its  spirals,  its  mobility  in  the  living 
state,  and  its  reaction  to  staining  media. 

The  Spirochceta  refringens,  which  frequently  exists 
on  the  surface  of  ulcerous  lesions  of  the  genital 
organs,  and  with  which  it  might  be  confused,  has 
not  so  many  spirals.  These  are  irregular,  very 
elongated,  and  not  deep  ;  it  changes  but  little  under 
the  influence  of  reagents  or  in  its  movements  ;  it  is 
thicker  than  the  treponema,  and  is  deeply  stained  bj' 
the  usual  stains. 

In  ulcerations  of  the  mouth,  and  even  of  the  lips. 


SYMPTOMS   AND  DIAGNOSIS  553 

there  is  a  possibility  of  confusion  with  other  micro- 
organisms, difficult  to  avoid,  even  by  an  expert 
observer.  The  greatest  precautions  must  be  taken, 
therefore,  when  the  diagnosis  of  syphilitic  chancre  of 
the  mouth  has  to  be  determined  by  bacteriological 
examination.  The  following  is  a  list  of  the  special 
characteristics  of  buccal  spirilla,  which  might  be 
confused  with  the  Treponema  pallidum. 

The  Spirillum  dentium  is  like  the  treponema  as 
regards  its  sUmness  and  the  regularity  of  its  spirals, 
but  differs  as  to  length  (4  to  10  fju  at  the  maximum), 
and  especially  in  the  slighter  depth  of  its  undulations. 

The  Spirochceta  huccalis  is,  on  the  other  hand,  easy 
to  recognise  on  account  of  its  great  length,  its  thick- 
ness, the  irregularity  of  its  spirals,  and  its  extreme 
mobihty. 

Vincent's  Spirillum  is  longer  and  thicker  than  the 
Treponema  pallidum,  its  spirals  are  irregular  and  not 
deep  ;   it  is  associated  with  the  fusiform  bacillus. 

The  Spirochceta  refringens  is  almost  the  only  spirillum 
which  may  be  confounded  with  the  Treponema  pal- 
lidum in  the  scrapings  obtained  from  ulcerations  of 
the  genital  organs. 

The  presence  of  the  treponema  in  the  scrapings  of 
an  ulceration  of  chancrous  appearance  enables  one 
to  prove  that  this  ulceration  is  a  syphilitic  chancre  ; 
but  its  absence  would  not  definitely  exclude  such  a 
diagnosis. 

Indeed,  it  is  by  no  means  exceptional  for  it  to  be 
absent  in  undoubted  cases  of  chancre. 

In  the  first  place,  it  may  have  been  dispersed  by 
the  use  of  antiseptics,  to  which  it  is  very  sensitive. 
Secondly,  the  surface  of  the  ulceration  may  be 
the  seat  of  various  secondary  infections,  the  patho- 
genic agents  of  which  have  caused  the  treponema  to 
disappear,  or  prevented  the  verification  of  its  presence 
in  the  scrapings.  I  have  already  shown  that  these 
two   causes   of   error  might  be   prevented   by  using 


554  SYPHILIS  AND   THE   ARMY 

dressings  and  bathings  of  boiled  water  for  forty-eight 
hours. 

Finally,  there  are  chancres  in  the  scrapings  of 
which  it  is  impossible  to  distinguish  the  presence  of 
the  treponema,  no  matter  what  care  is  taken.  These 
chancres  are  nearly  always  of  long  standing,  extending 
beyond  fifteen  or  twenty  days,  in  which  the  tissue  is 
more  or  less  sclerosed,  the  scrapings  yielding  but  the 
slightest  exudation,  and  in  which  even  deep  scari- 
fications do  not  succeed  in  reaching  the  foci  of  tre- 
ponemae. 

In  these  cases  it  would  be  possible  to  obtain  evidence 
of  the  treponema  from  sections  of  the  chancre, 
hardened  in  alcohol  and  impregnated  with  silver  after 
Bertarelli's  method  ;  but  it  would  be  necessary  to 
make  a  partial  excision  of  the  chancre,  and  the  patients 
might  refuse  to  submit  to  this  ;  further,  this  method 
of  examination  can  only  be  accomplished  in  a  well- 
appointed  laboratory.  It  could  not,  therefore,  be 
recommended  in  army  practice. 

Researches  for  the  Fixation  of  the  Complement  (Wasser- 
mann  Reaction). — ^Many  medical  men  beheve  that 
the  complement-fixation  test,  by  means  of  the 
method  of  Bordet  and  Gengou  called  the  Wassermann 
Reaction,  is  of  the  highest  importance  in  the  diagnosis 
of  syphihtic  chancre.  Every  day  soldiers  are  sent  to 
the  bacteriological  laboratories  with  a  note,  containing 
the  following  statement  :  "  Probable  syphihtic  chancre; 
kindly  make  a  Wassermann  Reaction." 

This  belief  is  wrong,  and  if  one  relied  upon  the 
result  of  the  Wassermann  Reaction  for  determining 
the  diagnosis  of  chancre,  it  would  be  erroneous  nine 
times  out  of  ten. 

The  views  of  medical  men  in  general,  and  even  of 
experts  in  the  Wassermann  Reaction,  are  very  vague, 
as  I  have  taken  the  opportunity  of  finding  out,  and, 
in  plain  words,  absolutely  false.  Many  medical  men 
practically  believe  that,  on  the  one  hand,  the  existence 


SYMPTOMS  AND  DIAGNOSIS 


555 


of  this  reaction  is  sufficient  to  establish  the  syphilitic 
nature  of  any  lesion  borne  by  the  patient  who  has 
supplied  the  serum  examined,  and,  on  the  other  hand, 
the  absence  of  this  reaction  is  sufficient  to  prove  that 
the  same  lesion  is  not  syphilitic. 

Without  speaking  of  the  intrinsic  value  of  a  Wasser- 
mann  test,  which  depends  upon  the  competence  of  the 
biologist  who  made  it,*  and  with  the  quality  of  the  anti- 
gen provided,  it  has  been  definitely  established  that 
this  reaction  does  not  appear  at  the  same  time  as  the 
chancre.  It  does  not  become  positive  until  the  end 
of  a  certain  time  and,  when  it  is  positive,  the  charac- 
teristics of  the  chancre  are,  as  a  rule,  so  clear  that  it 
brings  no  support  to  the  diagnosis. 

Blumenthal's  statistics,  which  are  already  old,  will 
give  some  idea  of  the  variations  of  the  frequency  of 
the  Wassermann  Reaction,  in  accordance  with  the  age 
of  the  chancre. 


Infections  dating  from 

Number 
of  cases 
studied. 

Positive 
Eeactions. 

?Jegative 
Reactions. 

Proportion 

per  100  of  the 

Positive 

Reactions. 

3  weeks 

11 

1 

10 

9  per  100 

4       „            ... 

17 

2 

15 

11     „     „ 

5       ,,            ... 

13 

6 

7 

46     „     „ 

6       „            ... 

23 

12 

11 

52     „     „ 

7       „            ... 

10 

11 

5 

68     „     „ 

8       „            ... 

13 

8 

5 

61     ,,     „ 

♦  The  Wassermann  Reaction  is  in  no  way  comparable  to  present 
chemical  reactions :  the  substances  used  for  the  examination 
(antigen,  complement)  are  of  variable  composition,  and  absolutely- 
unknown  dosage;  the  results  themselves,  i.e.  the  production  or 
not  of  haemolysis,  are  often  difficult  to  read  and  appreciate. 

Further,  it  is  not  rare,  with  the  same  serum,  to  see  one  observer 
obtain  a  negative,  and  another  a  positive,  reaction;  sometimes, 
indeed,  the  same  observer  wiU  obtain  a  positive  reaction  one  day 
and,  a  few  days  later,  a  negative  one. 

It  must  be  added  that  the  different  methods  employed  for  the 
performance  of  this  reaction  give  results  very  different  from  each 
other. 

Under  these  conditions,  in  estimating  the  reliance  to  be  placed 
on  a  reaction,  not  only  must  one  know  the  technique  followed,  but 
also  by  whom  the  examination  was  made. 


556  SYPHILIS   AND   THE   ARMY 

These  statistics  show  that  it  is  only  in  the  fifth  week 
that  the  proportion  of  positive  reactions  is  high  enough 
for  the  results  to  be  of  any  diagnostic  importance  in 
doubtful  cases  ;  and  at  this  period  there  is  not  long 
to  wait  before  secondary  symptoms  appear.  Even  in 
the  eighth  week  there  are  only  two  chances  out  of  three 
of  obtaining  a  positive  reaction. 

According  to  the  researches  of  Jeanselme  and 
Vernes,  the  intensity  of  the  Wassermann  Reaction  grow> 
progressively  during  the  course  of  the  evolution  of  the 
syphilitic  chancre.  Comparison  of  the  coloration 
obtained  in  several  successive  Wassermann  Reactions 
might  furnish  an  important  element  in  the  diagnosis 
of  chancre. 

Unfortunately,  these  comparative  colorimetric  tests 
presuppose,  at  the  same  time,  the  use  of  an  antigen 
of  exact  dosage  and  absolute  constancy,  with  great 
expertness  and  constant  experience  of  the  Wassermann 
Reaction  on  the  part  of  the  operator.  Even  in  civil 
practice,  in  times  of  peace,  they  are  so  difficult  that  I  do 
not  believe  they  have  been  followed  up  by  any  other 
observer. 

A  last  reflection  on  the  value  of  the  Wassermann 
Reaction  in  diagnosing  syphilitic  chancre.  Being 
produced  with  the  serum  of  old  syphilitics,  this  reaction 
occurs  when  they  are  affected  by  tertiary  ulcerous 
syphilides  of  the  genital  organs,  which  simulate  the 
chancre  and  have  merited  the  name  of  chancriform 
syphilides.  But  chancriform  syphilides  admit  of 
neither  the  same  prognosis  nor  the  same  treatment, 
nor  the  same  prophylactic  measures  of  isolation  as 
syphilitic  chancre.  One  sees  to  what  an  error  a  medical 
man  would  expose  himself  in  the  presence  of  such 
lesions  if  he  relied  solely  upon  the  Wassermann  Re- 
action, without  interpreting  it  by  means  of  clinical 
indications  and  the  patient's  previous  history. 

Therefore,  interesting  as  this  reaction  is  for  the 
diagnosis  of    secondary  syphilitic    lesions,   and    more 


SYMPTOMS   AND   DIAGNOSIS  557 

especially  of  tertiary  ones,  it  has  but  few  applications 
in  the  diagnosis  of  syphilitic  chancre. 

Differential  Diagnosis  of  Syphilitic  Chancre 

The  affections  most  often  confused  with  syphilitic 
chancre  of  the  genital  organs  are  :  genital  herpes, 
simple  chancre,  ecthyma,  scabies,  traumatic  ulcerations, 
balanitis,  gangrene  of  the  genital  organs,  ulcerations 
caused  for  the  purpose  of  simulation,  epithelioma  of 
the  penis,  secondary  and  tertiary  syphilides,  and 
certain  ulcerations  which  appear  after  arsenical  treat- 
ment of  syphilis. 

Genital  Herpes  is  characterised  by  circular  ulcera- 
tions generally  covered  by  a  whitish  coating,  isolated 
from  each  other,  frequently  multiple,  with  polycyclic 
contours.  These  ulcerations  are  deeper  than  those  of 
syphilitic  chancre  and  have  been  preceded  by  fine 
transparent  ephemeral  vesicles,  which  the  patients 
sometimes  remember,  but  not  always.  The  lesions 
appear  in  successive  crops,  and  in  some  cases  it  is 
possible  to  find  intact  vesicles  near  the  ulcerations. 
The  irritation  caused  by  dirty  dressings  may  induce  a 
certain  amount  of  basal  infiltration,  which  may  simulate 
the  induration  of  syphilitic  chancre,  but  it  is  softer,  and 
not  so  circumscribed  as  in  the  chancre. 

The  lymphatic  glands,  despite  what  Ricard  and 
Fournier  have  said,  are  influenced  by  genital  herpes  ; 
but  the  adenitis  accompanying  it,  unlike  that  of  a 
syphilitic  chancre,  is  slight  and  painful  on  pressure 
and  nearly  always  limited  to  one  gland. 

The  course  of  the  two  affections  is  different : 
herpetic  ulceration  heals  rapidly.  In  a  few  days,  in 
regions  in  which  there  is  no  moisture,  such  as  the  penis, 
it  is  replaced  by  a  dry  scab,  which  becomes  detached 
and  leaves  a  simple  macule,  which  disappears  in  fifteen 
to  twenty  days,  without  apparent  cicatrix.  In  moist 
regions  it  gradually  shrinks  up,  its  borders  disappear, 


558  SYPHILIS  AND   THE   ARMY 

and  for  some  days  it  remains  a  simple  reddish  spot, 
then  disappears  without  leaving  any  trace. 

Under  the  name  of  herpetiform  chancres,  a  variety 
of  syphilitic  chancres  have  been  described,  charac- 
terised by  their  small  dimensions  and  multiplicity  ; 
but,  no  matter  how  small  they  are,  they  are  always 
more  extensive  than  herpetic  ulcerations,  and  without 
their  poly  cyclic  contours. 

Genital  herpes  is  essentially  a  recurrent  affection  : 
its  outbreaks,  sometimes  accompanied  by  pain  in  the 
course  of  the  nerves  of  the  genital  organs,  or  of  the 
thigh  (Mauriac's  neuralgic  herpes),  recur  at  varied 
intervals.  The  fact  of  relapse  is  important  for  diag- 
nostic purposes.  Nevertheless,  one  must  not  rely  on 
the  existence  of  numerous  previous  attacks  of  herpes 
for  eliminating  syphilitic  chancre ;  the  more  so,  as  the 
syphilitic  virus  may  be  inoculated  in  the  herpetic 
erosions. 

A  first  attack  of  herpes,  occurring  in  a  young  man, 
and  especially  in  one  of  thirty  to  thirty-five,  no 
matter  how  characteristic  it  may  be,  must  cause 
reserve  as  to  the  possibility  of  the  later  appearance 
of  chancre.  As  a  matter  of  fact,  syphilitic  chancre 
is  sometimes  seen  to  develop  after  and  in  the  same 
place  as  a  grouj)  of  herpes  (prechancrous  herpes). 
Therefore,  it  is  indispensable,  in  the  case  of  a  first 
attack  of  herpes,  to  keep  the  patient  under  observa- 
tion during  fifteen  to  twenty  days. 

Simple  Chancre  differs  from  syphilitic  chancre  in  its 
irregular  configuration  and  irregular  surface,  by  the 
pus  or  yellowish  coating  which  covers  it,  and  especially 
by  its  characteristic  edges.  These  are  detached  to  a 
varying  depth,  but  always  enough  at  some  spot  to 
enable  the  point  of  a  probe  or  edge  of  a  spatula  to 
be  passed  under  them  ;  they  are  thin,  and  marked  bj^ 
a  fine  yellow  border,  similar  to  fresh  butter.  Moreover 
the  base,  even  if  infiltrated,  is  not  indurated  like  that 
of  the  syphilitic  chancre. 


SYMPTOMS  AND   DIAGNOSIS  559 

Simple  chancre  is  rarely  single  ;  the  lesions,  becoming 
easily  inoculated,  multiply  and  become  much  greater 
in  number  than  in  the  case  of  syphilitic  chancre. 

The  condition  of  the  lymphatic  glands  varies  ;  some- 
times they  are  painless  and  hardly  perceptible,  having 
retained  their  normal  consistency  ;  at  others  they  are 
often  painful  on  movement  and  pressure,  voluminous 
and  suppurating  (chancrous  buboes). 

The  secretory  products  of  multiple  chancre  contain 
a  more  or  less  abundant  quantity  of  Ducrey's  bacillus. 
The  elements  of  this  bacillus,  measuring  lyu-  5  in  length 
by  0/x  5  in  width,  are  isolated  or  united  in  fine  chains 
of  2  or  o,  with  rounded  extremities,  resembling  the 
figure  8  ;  they  are  easily  stained  by  Nicolle's  method 
(gentian  violet  and  tannin).  Their  demonstration  is 
not  easy,  and  can  only  be  done  satisfactorily  by  an 
expert  bacteriologist. 

A  very  important  characteristic  of  simple  chancre 
is  the  possibility  of  indefinite  inoculation  on  the  bearer, 
as  long  as  the  healing  process  is  not  advanced.  Inocula- 
tion is  made  by  means  of  a  lancet  or  vaccination 
needle,  intra-epidermically,  or  by  superficial  and  slight 
scarification.  Care  must  be  taken  to  avoid  both 
accidental  contamination  of  the  inoculated  spot  and 
reinoculations  of  the  experimental  chancre,  by  covering 
the  inoculated  region  with  a  watch-glass  held  in  position 
by  a  strip  of  diachylon  plaster.  At  the  end  of  the  first 
day  a  red  inflammatory  areola  apjjears  at  the  inocu- 
lated point,  having  nothing  characteristic  about  it ; 
but  on  the  third  day,  in  the  centre  of  the  areola,  the 
epidermis  is  raised  in  a  small  pustule  filled  with  turbid 
fluid  ;  on  the  fourth  day,  the  fluid  has  become  clearly 
purulent ;  the  small  pustule  bursts  and  leaves  a  cup- 
shaped  depression,  with  well-defined  borders  ;  during 
the  following  days,  the  chancre  increases  in  size  and 
depth,  its  borders  become  detached,  and  there  is  basal 
suppuration.  Naturally,  directly  the  experimental 
lesion  has  acquired  sufficiently  cleai  characteristics — 


560  SYPHILIS   AND   THE   ARMY 

that  is  to  say,  on  the  third  day,  or  at  latest  on  the 
fourth  or  fifth — its  progress  should  be  arrested,  which 
can  easily  be  done  by  cauterising  it  fairly  deeply  with 
the  thermo-cautery. 

Another  characteristic  of  simple  chancre  is  its  short 
incubation  period.  I  have  already  stated  that  a 
syphilitic  chancre  is  the  result  of  intercourse  fifteen  to 
twenty  days  previously  at  a  minimum,  whereas  simple 
chancre  appears  two  or  three  days  after  coitus.  There- 
fore, if  it  can  be  proved  that  no  sexual  relations  have 
taken  place  within  the  five  or  six  days  preceding  the 
development  of  ulceration  of  the  genital  organs,  this 
cannot  be  a  simple  chancre. 

In  fact,  there  are  rarely  many  difficulties  in  diag- 
nosing simple  chancre  ;  but  the  proof  of  its  presence 
does  not  mean  that  the  patient  has  escaped  syphilis. 
Indeed,  as  Rollet  has  shown,  the  difference  in  the 
duration  of  the  incubation  periods  of  simple  and 
syphilitic  chancres  produces  consequences  of  consider- 
able importance  from  the  theoretical,  as  well  as  from 
the  practical,  point  of  view,  which  are  as  follows  :  the 
two  viruses  having  been  inoculated  simultaneously 
during  the  course  of  a  single  coitus,  may  give  rise  to 
mixed  infection  ;  the  simple  chancre  appears  first  at 
its  normal  time,  and  develops  in  the  usual  way,  but  at 
the  end  of  the  syphilitic  incubation  period,  the  syphilitic 
chancre  develops  in  its  turn,  blends  its  characters  with 
those  of  the  simple  chancre,  and  gives  rise  to  general 
syphilitic  infection. 

In  such  a  case,  the  simple  chancre  does  not  at  first 
differ  in  any  way  from  that  which  results  from  inocula- 
tion of  its  own  virus.  Very  naturally,  therefore,  the 
medical  man  diagnoses  simple  chancre  ;  then,  at  the 
end  of  fifteen  to  twenty  days,  the  ulcerative  char- 
acteristics become  modified,  the  base  becomes  hard, 
without  any  error  of  treatment  or  secondary  infection 
the  surface  dries  up,  and  its  borders  are  less  detached 
sometimes  being  completely  levelled. 


SYMPTOMS   AND  DIAGNOSIS  561 

A  mixed  chancre,  according  to  the  happy  expression 
of  Rollet,  is  thus  formed ;  the  lymphatic  glands, 
which  have  been  immune  up  to  then,  become  hard, 
but  not  painful. 

It  is  not  always  easy  to  observe  the  transformation  ; 
this  can  only  be  done  by  careful  and  repeated  ex- 
aminations ;  sometimes,  at  the  end  of  several  daj^s, 
there  is  no  further  doubt  ;  at  other  times,  the  diagnosis 
remains  uncertain.  As  these  chancres  are  generally 
much  infected,  it  is  difficult  to  search  for  the  spirochsete. 
As  long  as  any  doubt  persists,  anti-syphilitic  treat- 
ment should  be  postponed,  and  sometimes  it  is  only 
the  appearance  of  roseola  and  secondary  symptoms 
which  enable  the  diagnosis  to  be  settled. 

Ecthyma  of  the  genital  organs  is  rare,  but  not 
absolutely  exceptional.  It  generally  affects  the  penis, 
most  frequently  in  the  form  of  scabs.  The  scab, 
thick,  greyish,  often  adherent,  covers  a  regularly 
rounded  ulceration,  with  well-defined  edges,  occasion- 
ally detached.  The  most  noticeable  characteristic  is 
th6  existence  of  abundant  suppuration  under  the 
crust,  forming  a  more  or  less  adherent  layer  over  the 
whole  surface  of  the  ulcer  ;  below  this,  the  base  of 
the  ulcer  is  bright  red,  bleeding  easily,  and  a  little 
uneven.  It  is  not  indurated.  Ecthyma  of  the  genital 
organs  is  often  accompanied  by  swelling  of  the  inguinal 
glands,  which  are  painful  on  pressure.  It  coincides 
most  frequently  with  ecthymatous  lesions  of  other 
regions,  especially  of  the  legs,  the  existence  of  which 
may  aid  diagnosis. 

Scabies,  which  has  a  predilection  for  the  human 
genital  organs,  generally  causes  small  papules  covered 
with  greyish  scabs.  These  lesions  cannot  be  cour 
founded  with  chancre,  as  they  are  generally  elongated, 
raised,  and  non-ulcerous.  When,  exceptionally,  they 
develop  into  large  pustules,  these  and  the  ulcerations 
which  succeed  them  have  all  the  characteristics  of 
ecthyma. 


562  SYPHILIS   AND   THE  ARMY 

The  existence  of  indubitable  signs  of  scabies  does 
not  imply  that  all  co-existent  ulcerations  of  the  genital 
organs  are  of  the  same  origin.  There  is  risk  of  syphili- 
tic inoculation  with  scabies,  on  account  of  the  solution 
of  continuity  it  causes,  and,  in  patients  suffering  from 
itch,  syphilitic  chancres  are  often  multiple,  owing  to 
the  multiplicity  of  these  solutions  of  continuity. 

Common  Excoriations  of  the  Genital  Organs,  infected 
as  the  result  of  uncleanliness,  may  become  sur- 
rounded by  an  inflammatory  infiltration  simulating 
chancrous  induration  ;  careful  examination,  however, 
will  show  that  there  is  no  true  induration.  Wet 
dressings  applied  for  two  or  three  days,  and  the 
suppression  of  all  causes  of  irritation,  will  induce  all 
trace  of  inflammation  to  disappear,  and  show  that  it  is 
merely  a  simple  lesion,  without  genuine  induration. 

Gangrene  of  the  Genital  Organs  begins  with  appar- 
ently simple  ulcerous  lesions,  often  with  basal  infiltra- 
tion, but  is  soon  revealed  by  the  presence  of  a  greyish 
or  blackish  plaque,  surrounded  by  an  infiltrated  zone 
which  is  liable  to  spread.  At  the  same  time,  there 
are  usually  general  symptoms  and  often  high  fever. 
There  is  no  possibility  of  confusion  with  syphilitic 
chancre.  There  are  cases,  however,  in  which  the 
gangrene  situated  on  the  gland  is  accompanied  by 
intense  oedematous  inflammation  of  the  prepuce  as 
in  concealed  chancres  of  the  prepuce.  The  existence 
of  the  eschar  is  only  manifested  by  a  discharge  of  sero- 
purulent  or  sanious  fluid  from  the  preputial  orifice, 
resembling  the  secretion  of  an  ulcerous  balanitis.  If 
this  fluid  is  collected,  its  gangrenous  odour  attracts 
attention  and  aids  in  determining  the  presence  of  a 
sub -preputial  eschar. 

Gangrenous  lesions  of  the  genital  organs  may 
develop  with  syphilitic  chancre  ;  hence  the  diagnosis 
of  gangrene  does  not  exclude  that  of  chancrp.  As 
chancre,  when  complicated  by  gangrene,  loses  all  its 
objective  characteristics,  and  further,  as  the  presence 


SYMPTOMS  AND   DIAGNOSIS  563 

of  various  micro-organisms,  and  specially  of  spirilla, 
on  the  surface,  prevents  the  discovery  of  any  trepon- 
ema  which  might  exist  there,  there  may  be  doubt  as 
to  the  presence  of  a  chancre.  In  a  case  of  gangrene 
of  the  genital  organs,  when  prolonged  observation  did 
not  enable  me  to  detect  any  secondary  syphilitic 
manifestation,  the  Wassermann  Reaction,  made  on 
several  occasions,  was  positive  once,  partially  positive 
another  time,  and  finally  became  and  remained 
negative.  I  was  told  of  another  altogether  similar 
case  by  Dr.  Ristitch.  There  is,  thus,  reason  to  sup- 
pose that  gangrene  of  the  genital  organs  may  cause  a 
temporary  Wassermann  Reaction,  and,  until  the  most 
complete  study  has  been  made  of  the  case,  the  diagnosis 
of  syphilis  should  be  suspended  till  the  secondary 
manifestations  have  appeared  to  corroborate  it. 

Ulcerations  induced  with  the  Object  of  Simulation  may 
present  objective  characteristics  resembling  those 
of  syphilitic  chancre.  All  the  same,  it  is  rare  for  the 
resemblance  to  be  close.  In  the  few  cases  I  have 
observed  it  was  generally  a  question  of  bums  from 
a  lighted  cigarette,  a  traumatism  which  produces 
regular  rounded  ulceration  resembling  simple,  more 
than  syphilitic,  chancre.  Even  when,  as  the  result 
of  repeated  irritations,  the  simulator  succeeds  in 
inducing  a  certain  degree  of  infiltration  of  the  ulcera- 
tive base,  this  is  more  diffuse  than  that  of  syphilitic 
chancre,  and  the  absence  of  treponema  is  against  this 
diagnosis. 

As  a  rule,  the  imitation  is  rougher  and  more 
clumsy  still.  I  recently  saw  a  dry,  adherent,  and 
circular  eschar  on  a  soldier,  who  stated  that  it 
was  due  to  sexual  intercourse  some  days  before,  and 
hoped  that,  thanks  to  this  lesion,  he  would  be  passed 
as  syphilitic  and  sent  to  hospital  for  some  time.  Even 
the  character  of  the  eschar,  which  was  adherent  and 
impossible  to  detach,  as  well  as  its  almost  circular 
configuration  with  an    angular  prolongation  at   one 


564  SYPHILIS  AND   THE   ARMY 

peripheral  point,  testified  to  its  artificial  origin.  I 
could  not  get  an  acknowledgment  of  trickery,  nor  a 
demonstration  of  the  caustic  employed,  but  I  have 
reason  to  believe  that  it  was  produced  by  oxalic  acid. 

Erosive  and  Ulcerous  Balanitis  is  manifested  by 
sero-purulent  secretion  and  erosions  :  these  erosions 
are  multiple,  irregular,  often  confluent,  without  basal 
induration,  and  can  hardly  be  confused  with  syphilitic 
chancre.  Their  acute  course,  rapid  cure  by  simple 
means,  and  the  absence  of  enlargement  of  the  inguinal 
glands,  are  points  which  settle  the  diagnosis. 

Epithelioma  is  rare  on  the  genital  organs.  It  may 
be  observed  there,  however,  even  in  men  called  up 
for  military  service. 

It  commences  either  as  a  smooth,  projecting  tume- 
faction, or  as  a  wart-like  growth,  which  evolves  slowly. 
It  is  only  at  the  end  of  several  months  that  ulceration 
appears  :  this  is  of  variable  extent,  is  often  covered 
by  a  sanious  secretion,  has  an  irregular  base  of  wood- 
like hardness.  The  prolonged  duration  of  the  affection, 
and,  in  default  of  a  precise  history  from  the  patient 
or  confidence  in  his  assertions,  the  characteristics  of 
the  basal  ulceration  and  extreme  hardness  of  the 
edges  should  remove  any  suspicion  of  syphilitic  chancre 
from  the  diagnosis. 

Syphilitic  lesions  may  sometimes  be  confused  with 
infective  chancre. 

Erosive  Mucous  Plaques  of  the  glans  and  prepuce 
consist,  like  the  chancre,  of  superficial  and  circular 
loss  of  substance  ;  but  they  are  even  more  superficial 
than  the  chancre,  while  their  border,  on  the  contrary, 
is  often  more  defined,  the  limit  between  the  healthy 
tegument  and  erosion,  even  if  the  plaque  is  not 
depressed,  is  abrupt,  and  marked  by  a  more  or  less 
definite  raised  border.  By  means  of  careful  palpation, 
it  can  be  shown  that  their  base  is  of  firmer  consistency 
than  the  adjacent  parts,  but  it  is  nothing  like  that  of 
chancrous   induration.     Sometimes,   however,   in   the 


SYMPTOMS   AND   DIAGNOSIS  565 

midst  of  the  erosive  plaques  with  hardly  any  infiltra- 
tion, one  will  be  encountered  which  is  generally  larger, 
with  a  slightly  raised  border  and  a  firm  base  ;  this  is  a 
mucous  plaque  developed  on  the  site  of  the  chancre, 
and  by  its  direct  transformation  before  complete 
cicatrisation. 

Certain  tertiary  ulcerations  of  the  prepuce  and 
especially  of  the  glans  simulate  chancres  so  much 
that  they  have  been  regarded  as  recurrences.  Alfred 
Foumier  has  called  attention  to  them  under  the 
name  of  chancrijorm  syphilides,  and  has  made  use  of 
their  existence  as  an  argument  in  support  of  his  too 
absolute  opinion,  that  a  chancre  never  recurs. 

Appearing  always  several  years  after  the  initial 
chancre,  sometimes  on  the  site  of  the  cicatrix,  these 
syphilides  generally  begin  as  a  rounded  projecting 
tumefaction,  which  softens  and  ulcerates  at  the  centre. 
In  a  few  days,  the  ulceration  attains  the  average  size 
of  a  small  hazel-nut ;  its  form  is  rounded,  its  surface 
depressed,  sometimes  deeply  excavated,  often  irregular 
and  mammillated,  its  borders  project,  clearly  marked, 
not  detached  ;  it  rests  upon  a  firm  infiltrated  base  ; 
the  infiltration  projects  beyond  the  ulceration  and 
forms  a  rounded  nodule  below  it,  differing  from  the 
induration  of  a  chancre. 

On  the  whole,  the  ulcerative  characteristics  are 
those  of  a  gumma  rather  than  a  chancre,  and  the 
histological  structure,  in  two  cases  I  was  able  to 
study,  was  that  of  gumma. 

The  absence  of  treponemas  in  the  scrapings  from 
the  ulceration,  the  positive  Wassermann  Keaction  from 
the  beginning  of  the  lesion,  the  tendency  to  persistence 
until  treatment  is  begun,  and  the  rapid  cicatrisation 
under  its  influence,  indeed  all  the  biological  and 
evolutive  characteristics,  as  well  as  the  details  of  the 
clinical  aspect,  are  those  of  ulcero-gummatous  tertiary 
lesions. 

A   certain   number   of   the   male   bearers   of   these 


566  SYPHILIS  AND   THE   ARMY 

ulcerous  lesions  blame  a  suspicious  coitus  as  the  cause 
of  their  appearance.  Finger  and  Landsteiner  inocu- 
lated tertiary  syphilitics  with  the  products  of  recent 
syphilitic  lesions  and  produced  at  the  point  of  inocula- 
tion, not  a  chancre,  but  a  tertiary  lesion,  thus  seeming 
to  give  some  probability  to  the  assertions  of  these 
patients.  This  is  a  question  requiring  investigation, 
which  we  need  not  consider  further  at  present.  It 
is  none  the  less  true  that  these  lesions  differ  pro- 
foundly from  chancre,  and  that,  contrary  to  genuine 
chancrous  recurrences,  they  do  not  give  origin  to  a 
fresh  attack  of  syphilis  with  secondary  symptoms. 

The  Pseudo-chancre  of  Syphilitics  treated  by  Arseno- 
benzol. — It  is  not  unusual  to  see  an  ulcerous  lesion 
appear  in  syphilitics,  who  have  been  subjected  to 
arsenical  injections,  at  the  same  j)oint  at  which  the 
initial  chancre  was  situated  and  somewhat  resembling 
the  syphilitic  chancre.  Some  too  zealous  partisans 
of  arsenical  medication  have,  without  hesitation, 
regarded  it  as  a  second  chancre,  and  a  proof  of  the 
sterilisation  of  syphilis  by  arsenobenzol. 

The  following  is  what  occurs  with  this  lesion,  accord- 
ing to  facts  I  have  observed. 

Some  variable  time  after  the  initial  chancre  and 
the  arsenical  treatment,  often  some  days  after  inter- 
course with  a  syphilitic  or  non-syphilitic  woman,  an 
ulceration  appears  at  the  site  of  the  chancre,  which 
in  a  few  days  spreads  and  attains  the  dimension  of  a 
sixpence,  a  shilling,  or  more  ;  sometimes  in  the  neigh- 
bourhood of  the  first,  one,  or  more  rarely  two,  other 
ulcerations  appear  within  the  space  oi  a  few  days. 

When  it  has  come  to  a  head,  the  round  or  slightly 
oval,  but  always  regular  and  clearly  defined  ulceration 
presents  a  regular  or  slightly  mammillated  base, 
covered  with  exudation  or  a  whitish-grey  detritus, 
rather  creamy,  and  fairly  easy  to  detach.  When  this 
exudation  is  removed  the  base  appears  red  and  some- 
times bleeds  easily.     The  borders  are  often  slightly 


SYMPTOMS   AND   DIAGNOSIS  567 

raised,  clearly  cut  out,  and  sometimes  slightly  detached 
in  places. 

The  lymphatic  glands  are  of  normal  size  or  slightly 
enlarged,  unless  they  have  remained  enlarged  alter 
the  healing  of  the  initial  chancre. 

The  ulceration  tends  to  persist  for  several  days. 
rarely  for  some  weeks  ;  it  heals  sometimes  under 
moist  dresshigs  of  boiled  water,  but  at  others  only 
responds  to  mercurial  treatment. 

Research  for  the  treponema  in  the  ulceration  scrap- 
ings gives  uncertain  results,  even  after  cleansing  the 
surface. 

The  Wassermann  Reaction  may  be  either  positive 
or  negative. 

If  the  patient  is  left  without  treatment,  there  is  no 
evidence  of  secondary  symptoms  during  the  following 
weeks,  as  there  would  be  if  it  were  a  case  of  syphilitic 
reinfection. 

Such  is  the  ulceration  which  has  been  erroneously 
regarded  as  a  recurrent  syphilitic  chancre  :  it  differs 
from  a  chancre  in  all  its  objective  characteristics,  by 
its  appearance  a  very  few  days  after  coitus,  the  usual 
absence  of  treponemas,  and,  finally,  by  the  absence 
of  secondary  symptoms  at  the  end  of  the  classical 
period  of  secondary  incubation. 

On  the  other  hand,  it  was  unknown  before  the  use  of 
arsenobenzol,  and  is  only  observed  in  syphihtics 
treated  by  the  arsenical  method.  It  cannot  be  attri- 
buted either  to  insufficient  or  excessive  doses  of  arseno- 
benzol, for  I  have  seen  it  appear  in  patients  who  had 
only  received  two  injections  of  arsenobenzol.  repre- 
senting about  1  gr.  of  this  substance,  and  in  others 
who  had  received  7,  8,  or  even  12  injections  of  2.  4. 
or  5  grammes. 

This  lesion  requires  further  study.  At  present,  it 
may  be  considered  as  one  of  the  consequences  of 
arsenical  treatment,  a  consequence  without  any  great 
clinical  importance  or  apparent  gravity,  and  of  which 


568  SYPHILIS  AND   THE  ARMY 

the  pathogenesis  and  conditions  of  development  are 
not  yet  completely  determined.  But  it  should  not  be 
considered  as  a  morphological  deviation  of  chancre,  nor 
as  a  recurrence  of  syphilitic  infection.  Its  existence, 
without  denying  the  possibility  of  a  syphilitic  reinfec- 
tion after  treatment  by  arsenobenzol,  should  make  one 
very  cautious  in  interpreting  cases  of  second  chancre, 
and  permits  one  to  challenge  a  certain  number  of  the 
observations  pubUshed  in  support  of  the  occurrence 
of  this  reinfection. 

EXTRA-GENITAL   CHANCRES 

The  syphilitic  chancre  may  occupy  all  regions  of  the 
body  without  exception.  The  frequency  of  extra- 
genital chancres,  their  aspect  even,  which  is  unusual 
or  at  least  deceptive  in  many  of  them,  and  especially 
the  anomalous  manner  of  contamination  they  generally 
show,  give  a  special  interest  to  their  study. 

Extra -genital  chancres  do  not  appear  to  be  very 
frequent  in  the  Army,  according  to  Carle's  statistics. 

Nevertheless,  despite  their  infrequency,  owing  to  the 
"difficulties  of  diagnosis  they  sometimes  present,  it  is 
necessary  to  give  an  adequate  account  of  their  two 
most  usual  locaHsations,  these  being  the  only  places 
in  which,  up  to  the  present,  I  have  observed  them  in 
soldiers.* 

The  first,  chancre  of  the  lips,  is  important,  because 
of  its  frequency  ;  the  other,  chancre  of  the  tonsils,  on 
account  of  the  diagnostic  errors  to  which  it  is  hable. 

Chancre  of  the  Ups  is  not  necessarily  non-venereal 

*  Mention  must,  however,  be  made  of  chancre  of  the  beard 
(cheek  and  especially  chin),  usually  the  result  of  inoculation  by  the 
barber,  by  means  of  a  razor  or  shaving-brush  which  has  been  used 
to  shave  a  syphilitic.  This  chancre  is  often  extensive  and  covered 
with  scabs,  below  which  is  found  a  vegetating  or  oozing  surface; 
its  base  is  sometimes  red,  of  inflammatory  aspect,  but  manifestly 
indurated.  The  most  important  diagnostic  characteristic  is  the 
adenopathy  (sub- maxillary  or  sub- mental,  according  to  the  position), 
often  enormous,  which  accompanies  it. 


SYMPTOMS  AND  DIAGNOSIS  569 

any  more  than  chancre  of  the  tonsils  ;  both  may  be, 
and  often  are,  transmitted  by  kisses  or  the  projection 
into  the  mouth  of  sahva  charged  with  syphilitic 
products. 

Still,  the  mere  fact  of  the  localisation  is  sufficient 
index  for  admitting  the  possibility  of  contamination  by 
accidental  non-venereal  contact  (tumbler,  fork,  pipe, 
end  of  cigarette,  dentist's  instrument,  etc.)  ;  an 
inquiry  is  the  only  way  of  determining  whether  this 
presumption  is  well  founded.  This  inquiry,  however, 
is  often  extremely  difficult,  especially  with  subjects 
whose  interest  it  is  to  disguise  the  real  cause  of  con- 
tamination and  attribute  their  malady  to  "  innocent  " 
contact. 

Chancre  of  the  Lips. — A  syphilitic  chancre  may  occupy 
both  lips,  but  is  much  more  frequent  on  the  lower 
than  on  the  upper  lip  ;  its  most  usual  position  is  in 
the  centre  involving  both  cutaneous  and  mucous  por- 
tions. 

Of  round  shape,  it  projects  from  the  free  border  of 
the  lip  in  the  shape  of  a  pastille,  the  fore  part  of  which 
is  covered  by  a  brownish,  adherent  scab  ;  removal  of 
the  scab  is  painful  and  sometimes  causes  bleeding. 
The  surface  is  generally  bright  red,  firm,  smooth, 
regular,  and  clearly  defined. 

If  the  patient's  mouth  is  opened,  the  posterior  part 
of  the  ulceration,  which  continues  the  contour  of  the 
anterior  part  and  completes  the  circumference,  appears 
moist  and  red,  or  covered  by  a  whitish-grey  coating, 
often  resembhng  that  of  mucous  plaques. 

The  ulceration,  of  variable  extent,  from  the  size  of 
a  lentil  to  that  of  a  sixpence  or  larger,  rests  on  a  tume- 
fied base  ;  the  lip  is  deformed  by  this  tumefaction  and 
everted. 

On  palpation,  the  base  of  the  chancre  is  hard.  The 
induration  must  be  looked  for  in  the  same  way  as  that 
of  chancre  of  the  genital  organ  and  is  easy  to  perceive, 
but  often  surrounded  by  an  infiltrated  zone,  which 


570  SYPHILIS  AND  THE  ARMY 

must  be  pressed  upon  in  order  to  distinguish  the 
induration  itself. 

The  adenopathy  of  chancre  of  the  Hps  is  always  con- 
siderable and  can  be  observed  from  a  distance.  It 
affects  the  sub-maxillary  or  sub-mental  glands,  forming 
a  rounded  eminence,  often  the  size  of  a  pigeon's  egg. 
Palpation  enables  one  to  recognise  one  or  more  of 
the  glands  surrounded  by  an  inflammatory  zone  of 
periadetiitis,  which  sometimes  seem  to  be  adherent 
to  the  maxillary  bone. 

The  diagnosis  of  chancres  of  the  lips  is  easy.  Its 
development  within  a  few  days,  often  following  an 
excoriation  which  has  been  present  for  some  time, 
and  which  has  rapidly  become  "  festered,"  the  eversion 
of  the  lip,  basal  induration,  and  considerable  enlarge- 
ment of  the  glands,  prevent  all  confusion  with  cancerous 
or  other  ulcerations  of  the  region.  Simple  lesions, 
inflamed  by  local  irritation  and  especially  by  unsuit- 
able dressings,  may  deceive,  but  their  form  is  rarely 
as  regular  as  that  of  chancre,  and  they  are  accompanied 
neither  by  marked  basal  induration  nor  by  voluminous 
adenopathies. 

Microscopic  examination  of  the  scrapings  is  of  httle 
value  in  these  cases,  for  the  lips  harbour  a  large  number 
of  different  parasites,  especially  spirilla,  which  dissimu- 
late the  presence  of  the  treponema  or  may  be  confused 
with  it. 

Chancre  of  the  Tonsil. — ^Tonsillar  chancre  is  rare, 
but  is  hable  to  such  frequent  diagnostic  errors  that 
the  syphilis  to  which  it  gives  origin  is  generally  not 
recognised  until  the  secondary  symptoms  appear. 

It  occupies  one  tonsil  only,  covering  it  almost 
entirely,  but  rarely  extends  beyond  it.  Its  usual  size 
is  that  of  a  sixpenny  piece  ;  its  shape  is  round,  oval, 
or  irregular.  It  sometimes  appears  as  an  erosion 
of  a  greyish,  opahne,  or  red  coloration,  regular  and 
smooth  at  the  base,  or  made  uneven  by  the  irregularities 
of  the  tonsillar  surface  ;    at  other  times  it  may  be 


SYMPTOMS  AND  DIAGNOSIS  571 

ulcerous,  even  deeply  so,  of  a  reddish-brown  or  grey 
coloration  ;  occasionally  it  is  covered  by  a  pseudo- 
membranous exudation,  white,  thick,  adherent,  re- 
i^embling  that  of  diphtheria. 

Whatever  its  clinical  form,  tonsillar  chancre  always 
has  two  important  characteristics  : 

(1)  Basal  induration,  appreciable  with  the  finger 
(covered  for  precautionary  measures  with  a  rubber 
finger-stall),  or  with  a  rigid  instrument,  tongue-depres- 
sor, etc.,  which  should  be  handled  gently  and  not 
pressed  on  its  circumference,  as  in  the  examination  of 
chancre  of  the  genital  organs,  but  on  the  surface  itself. 

(2)  Enlargement  and  induration  of  the  lymphatic 
glands  in  the  region  of  the  .angle  of  the  jaw  are  often 
appreciable  to  sight  and  always  to  palpation. 

Contrary  to  most  other  localisations  of  syphihtic 
chancre,  tonsillar  chancre  is  frequently  painful,  owing 
both  to  its  seat  upon  a  mobile  region  and  to  the 
secondary  infection  of  its  surface.  While  often  slight 
at  the  onset,  within  a  few  days  the  pain  becomes  acute, 
and  persists  for  several  weeks. 

The  diagnosis  of  chancre  of  the  tonsil  depends  more 
on  the  basal  induration  and  sub-maxillary  adenopathy 
than  on  the  characters  of  the  ulceration,  which  vary  in 
different  cases  and  may  simulate  the  most  diverse 
affections  :  simple  tonsillitis,  Vincent's  angina,  diph- 
theria, tonsillar  abscess,  tertiary  syphiHdes,  tuber- 
culous ulcerations,  even  epithelioma  of  the  tonsil  and 
gangrene  of  the  pharynx. 

It  is  impossible  here  to  enter  into  the  differential 
diagnosis  of  these  different  affections,  a  diagnosis 
which  is  often  difficult,  even  for  skilled  speciaHsts, 
syphilologists,  or  laryngologists.  I  consider  that, 
whenever  a  medical  man  has  the  shghtest  suspicion  of 
chancre  of  the  tonsil,  he  should,  without  delay,  send  the 
patient  for  examination  by  a  syphilologist  or  laiyn- 
gologist.  I  cannot  emphasise  too  much  the  difficulties 
encountered  in  the  bacteriological  examination  of  such 


572  SYPHILIS   AND   THE   ARMY 

lesions  :  it  is  practically  impossible  to  discover  the 
treponema  in  the  scrapings  of  tonsillar  chancre  ;  on 
the  other  hand,  numerous  spirilla  may  resemble  it 
and  deceive  an  observer  who  is  not  sufficiently  wary  ; 
finally  the  existence  in  the  scrapings  of  clearly 
differentiated  micro-organisms,  even  Loeffler's  bacillus, 
is  not  sufficient  to  eliminate  the  possibihty  of  a 
chancre  evolving  at  the  same  time  as  another  tonsillar 
infection, 

SECONDARY  SYPHILIS 

Syphilitic  chancre,  with  its  satellite  adenopathy, 
constitutes  the  whole  symptomatology  of  primary 
syphilis  ;  it  may  even  be  already  cicatrised  before 
any  clinical  sign  reveals  general  infection  of  the 
economy. 

But  after  a  period,  called  that  of  second  incubation^ 
which  from  the  beginning  of  the  chancre  is  generally 
forty-two  to  forty-five  days,  roughly  six  weeks, 
general  syphilitic  symptoms  begin  to  appear  in  cases 
which  have  not  been  modified  by  intensive  treatment, 
constituting  the  secondary  period  of  the  disease. 

In  this  chapter  I  shall  limit  myself  to  summarising 
the  principal  manifestations  of  secondary  syphilis. 
For  the  military  surgeon,  they  are  relatively  less 
important  than  the  chancre,  not  because  they  are  less 
frequent  in  the  Army,  but  because  diagnosis  is  gener- 
ally easier,  owing  to  the  history  of  the  initial  chancre, 
generally  easy  to  obtain,  because  their  clinical  forms 
are  less  varied  than  those  of  chancre,  and  also,  because 
the  Wassermann  Reaction  is  almost  constantly  positive. 

General  Phenomena 

The  secondary  period  is  accompanied  by  general 
phenomena  :  fever  of  variable  type,  which,  in  rare  cases, 
may  simulate  typhoid,  more  or  less  marked  general 
malaise,  anaemia,  the  hsematological  characters  of  which 


SYMPTOMS  AND  DIAGNOSIS  573 

are  still  indefinite,  emaciation,  often  headache  varying 
in  intensity,  generally  nocturnal,  sometimes  continuing 
during  the  night  and  preventing  sleep  ;  the  lymphatic 
glands  become  enlarged  and  can  be  felt  in  all  regions 
accessible  to  palpation,  especially  at  the  nape  of  the 
neck,  in  the  neck,  and  above  the  olecranon.  The 
viscera  are  subjected  more  or  less  to  the  action  of  the 
pathogenic  agent  of  syphilis  ;  they  react  sometimes 
in  the  form  of  chnically  appreciable  disturbances  ; 
as  a  rule,  however,  no  symptoms  reveal  their  implica- 
tion. 

Cutaneous  Lesions 

The  secondary  period  is  especially  that  of  cutaneous 
lesions. 

These  lesions  {secondary  syphilides)  have  the  follow- 
ing general  characteristics  :  rounded  form  ;  a  tendency 
to  form  circles  or  semicircles  when  grouped  on  neigh- 
bouring points;  red  coloration, due  to  the  combination 
of  cutaneous  congestion  with  a  certain  degree  of  dermic 
infiltration  and  pigmentation,  a  coloration  which  has 
been  compared  to  that  of  copper,  or  lean  ham  ;  some- 
times, but  less  often  than  is  generally  beheved,  there  is, 
•at  the  periphery,  a  sHght  epidermic  elevation  (Biett's 
collar)  ;  the  tendency  to  generahsation  or  at  least  to 
very  considerable  extension,  contrasts  with  the  regional 
limitation  of  tertiary  lesions  ;  the  tendency  of  the 
lesions  to  polymorphism,  is  very  great  in  certain 
papular  forms  ;  the  absence  of  pruritus  ;  finally,  the 
tendency — ^an  exception  being  made  to  a  particular 
form  of  syphiHdes  occurring  in  malignant  syphilis — to 
heal  without  cicatrisation,  but  often  leaving  a  cutaneous 
pigmentation  which  persists  for  some  time. 

The  co-existence  of  a  positive  Wassermann  Reaction 
may  aid  diagnosis. 

The  cutaneous  lesions  of  secondary  syphilis  present 
the  most  varied  dermatological  types. 

Roseola. — The    erythematous    type,    or    roseola,    is 


574  SYPHILIS   AND   THE   ARMY 

the  most  simple  and  the  most  frequent  of  all  secondary 
syphilides .  Generally  appea li  ag  towards  the  forty-fifth 
day  after  the  beginning  of  the  chancre,  syphilitic 
roseola  first  appears  on  the  abdomen,  then  the  internal 
surface  of  the  thighs  and  trunk,  afterwards  extending 
to  the  neck  and  upper  arms.  The  first  pale,  round 
elements  may  be  difficult  to  recognise,  and  should  be 
looked  for  carefully  ;  they  soon  multiply  from  da}^ 
to  day,  till  in  a  few  days  the  eruption  is  complete. 
The  medical  man,  who  has  been  obliged  to  await  the 
appearance  of  roseola  before  determining  the  diagnosis 
of  an  ulceration  of  the  genital  organs,  should  look 
out  for  it  about  the  fortieth  day  after  the  commence- 
ment of  the  chancre  ;  when  he  has  detected  a  few 
red  spots  all  doubt  will  be  removed  by  their  rapid 
multiplication. 

Roseola  consists  of  round  spots,  sometimes  with 
ill-defined  borders,  the  size  of  a  lentil  to  that  of  a 
threepenny  piece,  isolated  from  each  other  ;  these 
spots  are  sometimes  flat  {macular  roseola),  sometimes 
raised  {papular  roseola),  or  sprinkled  with  small  pro- 
jections {granular  roseola),  sometimes  raised  and  of  a 
paler  colour  (Alfred  Fournier's  urticarial  roseola). 

The  colour  of  roseola  disappears  under  pressure, 
leaving  a  slight  yellowish  macule. 

If  not  treated,  syphilitic  roseola  persists  for  several 
weeks  ;  whereas,  under  the  influence  of  treatment, 
it  quickly  fades  and  disappears  gradually,  without 
causing  desquamation  or  leaving  any  trace  beyond 
a  very  minute  macule,  faintly  pigmented,  which  dis- 
appears in  its  turn  in  a  few  days. 

Along  with  this  form  of  generalised  roseola  with 
round  elements  of  small  dimensions,  which  appears 
towards  the  seventh  week  of  syphilis  and  is  nevei- 
reproduced  during  the  whole  course  of  the  disease, 
another  erythematous  syphilide  must  be  mentioned, 
known  under  the  name  of  recurrent  or  delayed  roseola. 
'I'his   appears  at   varying  times,   from   three   months 


SYMPTOMS   AND   DIAGNOSIS  575 

to  fifteen  months,  rarely  later,  and  may  recur  once 
or  twice  ;  it  consists  of  rose-coloured  spots,  paler 
than  those  of  early  roseola,  and  of  larger  dimensions, 
reaching  the  size  of  a  two-shilling  piece.  These  spots, 
like  those  of  early  roseola  are  sometimes  nummular 
and  of  uniform  coloration  over  their  whole  surface  ; 
they  are  often  circinate,  their  rose  contour  forming 
a  more  or  less  complete  crown  around  a  zone  of  normal 
skin.  The  spots  -  disappear  on  pressure  ;  they  are 
much  less  numerous  than  those  of  early  roseola,  and 
are  often  limited  to  one  region  of  the  body,  principally 
the  abdomen,  but  sometimes  to  the  limbs. 

This  recurrent  roseola  may  develop  in  patients  who 
had  previously  presented  early  roseola  at  the  normal 
date  ;  but  it  is  observed  much  more  frequently  in 
subjects  who  have  been  given  arsenobenzol  at  the 
beginning  of  syphilis,  and,  not  having  followed  regular 
treatment,  have  never  had  roseola.  The  interval 
between  treatment  and  the  commencement  of  delayed 
roseola  is  most  variable,  being  three  to  four  months 
most  frequently.  It  appears  that  arsenobenzol,  in 
inhibiting  the  appearance  of  the  symptoms,  has  merely 
retarded  the  eruption,  which,  at  the  period  at  which 
it  eventually  appears,  no  longer  does  so  under  the 
form  of  generalised  early  roseola. 

Diagnosis  of  Syphilitic  Roseola. — Roseola,  whether 
early  or  delayed,  can  hardly  be  confounded  with  any 
of  the  great  exanthems,  morhilli,  rubella,  which  are 
easy  to  recognise  by  their  exanthematous  characteris- 
tics, rapid  appearance,  and  general  concomitant 
phenomena. 

Medicamental  Erythemas,  induced  by  various  drugs 
(quinine,  antipyrine,  chloral,  etc),  may  appear  in  the 
form  of  isolated  spots,  resembling  roseola ;  their 
rapid  development  and  especially  the  sensations  of 
heat  and  pruritus  which  accompany  them,  distinguish 
them  from  this  form  of  syphilide. 

Giherfs  Pityriasis  rosea  is  frequently  mistaken  for  a 


576  SYPHILIS  AND  THE  ARMY 

syphilitic  roseola.  It  is  only  necessary  to  bear  in 
mind  the  existence  of  this  affection  and  the  possibiUty 
of  confusion  in  order  to  avoid  it.  Pityriasis  rosea  is 
characterised  by  a  more  or  less  abundant  eruption  of 
rose  spots,  of  very  varied  dimensions,  round  when 
small,  more  frequently  irregularly  oval  as  soon  as 
they  attain  the  size  of  a  sixpence,  with  rose-coloured 
contour,  and  bright  chamois  yellowish  centre.  The 
epidermis,  which  is  always  intact  in  syphilitic  roseola, 
is  slightly  creased  in  pityriasis  rosea,  and,  when  the 
skin  is  stretched  in  the  direction  of  the  long  axis  of 
the  plaque,  it  takes  on  the  appearance  of  crepon  ; 
moreover,  without  actually  desquamating,  it  is  often 
raised  at  the  periphery  of  the  chamois-coloured  zone 
forming  a  fine  white  border.  Pityriasis  rosea  gener- 
ally commences  with  a  large  oval  patch  (Blocq's 
"  mother  plaque  "),  which  may  attain  the  size  of  a 
two-  to  five-shilling  piece  ;  this  may  appear  on  any 
part,  usually  the  upper  portion  of  the  thorax,  from 
whence  other  spots  extend  progressively  to  the  abdo- 
men. The  former  existence  of  syphilitic  chancre  and 
the  co-existence  of  mucous  plaques  are  not  sufficient 
to  exclude  the  presence  of  pityriasis  rosea,  for  this 
disease  sometimes  develops  during  the  course  of  se- 
condary syphilis,  without  any  accountable  reason. 

Papular  Ss^hilides. — The  cutaneous  papular  lesions 
of  secondary  syphilis  are  frequent  and  of  varied  aspect. 

Several  very  different  kinds  must  be  described  : 

1.  The  syphilitic  plaques  of  Bazin  and  Legendre, 
characterised  by  circular  prominences,  with  sharp 
(•ontours,  round  or  oval,  and  red  or  brownish  periphery  ; 
the  slightly  depressed  centre,  generally  of  a  brown 
colour,  often  shows  superficial  desquamation.  These 
lesions  appear  at  a  variable  date  of  the  secondary 
period,  sometimes  before  the  roseola,  but  more  fre- 
quently during  its  course  and  decline,  and  are  often 
situated  on  the  neck  and  upper  part  of  the  trunk. 

Lesions  of  the  palms  of  the  hands,  frequent  during 


SYMPTOMS  AND  DIAGNOSIS  577 

the  secondary  period,  generally  under  the  defective 
name  of  pahnar  psoriasis,  must  be  included  amongst 
syphilitic  plaques.  They  consist  of  a  central  zone 
stripped  of  its  epidermic  covering  and  surrounded  by 
a  circular  squamous  elevation  of  variable  thickness. 
They  are  situated  symmetrically  on  both  hands  in 
varying  numbers,  sometimes  being  very  numerous  > 
They  may  appear  at  any  time  in  the  secondary  period, 
and  are  cured  completely  by  syphilitic  treatment. 

In  the  folds  (axillae,  umbilicus,  inguino-crural 
region,  inter-gluteal  fold,  commissures  of  toes),  the 
plaques  become  exudative  or  ulcerated,  and  their 
appearance  is  absolutely  identical  with  that  of  plaques 
of  the  external  genital  organs  ;  like  them,  they  may 
become  hypertrophic. 

In  the  beard  and  scalp,  they  are  covered  by  raised 
scabs,  sometimes  forming  thick  and  oozing  patches  of 
varying  size. 

Syphilitic  plaques  are  frequent  on  the  genital  organs, 
and  sometimes  remarkably  recurrent.  Of  erosive 
form  on  the  prepuce  and  glans,  where  they  resemble 
mucous  lesions  (hence  the  name  of  mucous  plaques), 
on  the  scrotum  they  are  erosive  or  ulcerous,  often 
hypertrophic,  prominent,  and  of  papillomatous  appear- 
ance. 

2.  Papular  syphilides  with  large  papules,  which 
often  begin  before  the  disappearance  of  the  roseola, 
are  characterised  by  flat  papules,  rarely  very  pro- 
minent ;  their  dimensions  may  reach  and  exceed 
those  of  a  large  pea  or  a  small  hazel-nut ;  generally 
well  defined,  surrounded  by  a  collar  of  epidermic 
desquamation,  they  are  of  a  more  or  less  deep  reddish- 
brown  colour  and  of  firm  consistency.  After  a 
duration  which  is  only  limited  by  treatment,  they 
subside  and  their  colour  fades,  but  a  brown  pigmented 
patch  remains  for  several  weeks,  or  months  ;  some- 
times wheals,  when  the  eruption  is  situated  on  the  trunk . 
Scales   of   varying   thickness   may   develop   on   the 


578  SYPHILIS   AND   THE  ARMY 

papules,  resembling  sometimes  those  of  pityriasis, 
sometimes  these  of  psoriasis  ;  the  syphilides  then  take 
the  name  of  papulosquamous  syphilides. 

The  large  papular  syphilides  may  be  situated  on 
any  region  of  the  body,  but  have  a  certain  predilection 
for  the  body,  and,  in  alcoholics,  for  the  face. 

They  are  indicative  of  grave  syphilis,  and  nearly 
always  coincide  with  an  abundant* lymphocytosis  of 
the  cerebro-spinal  fluid  (Ravaut). 

3.  Syphilides  with  small  papules  always  appear  after 
roseola,  sometimes  at  the  moment  of  its  disappearance 
and  on  the  spots  of  the  roseola.  They  have  a  tendency 
to  form  irregular  groups,  reminding  one  of  constella- 
tions of  stars,  the  groups  being  irregularly  distributed 
over  the  trunk,  but  rarely  on  the  limbs. 

Their  elements,  developed  around  the  hair-follicles 
(hence  the  name  of  follicular  syphilides)  vary  in  appear- 
ance in  different  cases,  often  indeed  in  different  groups 
of  elements  in  the  same  patient,  even  in  different 
elements  of  the  same  group  ;  thus  exhibiting  a 
polymorphism  more  pronounced  than  in  any  other 
syphilide. 

Some  are  prominent,  acuminated,  or  smooth, 
covered  by  adherent  epidermis,  sometimes  shining 
{lichenoid  syphilides,  still  erroneously  called  syphilitic 
lichen) ;  others  have  a  slight  central  desquamation 
corresponding  to  the  orifice  of  the  hair-follicle,  or  a 
very  small  pustule,  which  dries  up  and  is  replaced  by 
a  thin  scab  {acneiform  syphilide),  also  wrongly  called 
syphilitic  acne). 

These  elements  do  not  exceed  a  grain  of  millet- 
seed  in  size,  hence  the  name  m,iliary  syphilides  which 
has  been  given  them. 

Small  papular  syphilides  are  often  very  resistant 
to  treatment,  even  to  an  intensive  course  of  arseno- 
benzol. 

They  may  be  confused  with  Wilson's  lichen,  from 
which  they  differ  essentially,  besides  their  objective 


SYMPTOMS   AND  DIAGNOSIS  579 

characteristics,  in  the  absence  of  pruritus,  and  especially 
with  follicular  tuberculide  or  lichen  scrofulosorum,  of 
which  the  elements  occupy  the  same  positions,  and 
are  disposed  in  the  same  way,  but  are  larger  and 
tend  to  suppurate  ;  moreover,  lichen  scrofulosorum 
is  only  found  in  patients  with  active  tubercular  lesions, 
specially  adenitis  and  suppurative  osteo-arthritis. 

Vesicular,  Bullous,  and  Pustular  Syphilides. — These 
are  rare  ;  the  diagnosis  rests  upon  the  co-existence 
of  syphilitic  lesions  in  other  situations,  and  on  the 
previous  existence  of  chancre. 

i^lcerative  Syphilides. — Ulcerative  lesions  are  rare 
during  the  secondary  period.  They  constitute  a 
special  form  of  syphilis,  known  under  the  name  of 
malignant  syphilis,  which  some  authors  have  wrongly 
wished  to  separate  from  syphilis. 

They  commence  with  flat  nodules  of  a  red  or  brownish 
colour  which  rapidly  soften,  forming  round  ulcers 
with  sharply  cut  borders  and  an  irregular  base,  covered 
by  pus  or  by  dry  grey  scabs,  often  Umpet-shaped  ; 
at  the-  circumference  of  the  ulcer  is  a  red  zone  of 
infiltration  of  variable  extent.  These  ulcers  may 
reach  three  to  four  centimetres  in  diameter  or  more. 
They  leave  behind  them  deep  circular  cicatrices,  often 
surrounded  by  a  pigmented  zone. 

The  ulcers  may  be  irregularly  distributed  all  over 
the  body  ;  they  have,  however,  a  predilection  for  the 
lower  limbs.  On  the  face,  where  they  are  seen  but 
rarely,  they  sometimes  cause  extensive  destruction 
and  leave  considerable  deformity  behind  them. 

Malignant  syphilis  occurs  in  patients  debilitated  by 
privations,  serious  illnesses,  and  in  "  lymphatic  " 
subjects.  It  appears  to  be  but  rarely  observed  in  the 
Army. 

Pigmentary  Syphilide. — The  pigmentary  syphilide 
is  much  more  common  in  a  woman  than  a  man,  but 
it  frequently  attains  a  size  and  intensity  in  the  latter 
which  is  altogether  exceptional  in  a  woman. 


580  SYPHILIS   AND   THE   ARMY 

Contrary  to  the  teaching  of  Alfred  Fournier,  who 
regarded  it  as  a  lesion  sui  generis,  it  is  to-day  well  estab- 
lished that  the  pigmentary  syphilide  always  follows 
in  situ  a  previous  cutaneous  lesion,  most  frequently 
roseola,  more  rarely  syphilitic  plaques  of  the  skin  or 
papular  syphilides.  It  is  characterised  by  a  greyish- 
brown  coloration,  of  varying  intensity,  occupying  the 
neck  symmetrically  ;  on  this  pigmented  and  patchy 
surface  are  disseminated  round  areas,  the  colour  of 
which,  by  contrast  with  the  surrounding  pigmentation, 
seems  paler  than  that  of  the  normal  skin  ;  these  areas, 
of  a  round  or  oval  form,  are  of  variable  dimensions, 
generally  on  an  average  that  of  a  large  pea  ;  their 
boundaries  are  well  defined  ;  their  site  and  dimensions 
correspond  exactly  to  that  of  the  eruptive  element, 
which  preceded  the  pigmentary  syphilide. 

In  another  variety  of  the  pigmentary  syphilide 
the  pigmentation  forms  a  border  to  the  less  dark 
zones. 

The  favourite  site  of  the  pigmentary  syphilide  is  the 
neck,  principally  on  the  anterior  and  lateral  surfaces  ; 
from  there  it  may  extend  to  the  upper  part  of  the 
thorax  and  on  to  the  back. 

In  very  extensive  forms,  which  are  relatively  frequent 
in  man,  it  is  not  limited  to  the  cervical  region,  but 
occupies  the  periaxillary  regions  in  front  and  behind, 
sometimes  the  groins,  and  may  even  extend  to  the 
trunk. 

The  pigmentary  syphilide,  once  established,  persists 
for  several  months,  and  only  disappears  very  slowly, 
no  matter  how  intense  the  antisyphilitic  treatment. 
It  is  of  great  value  in  diagnosis. 

The  co-existence  of  cerebro-spinal  lymphocytosis, 
established  by  Ravaut,  gives  a  certain  prognostic 
importance  to  the  pigmentary  syphiHde,  and  is  an 
indication  for  energetic  treatment,  in  order  to  prevent 
the  later  development  of  serious  lesions  of  the  nervous 
centres. 


SYMPTOMS  AND  DIAGNOSIS  581 

Syphilitic  Alopecia 

Alopecia  is  frequently  a  symptom  of  secondary 
syphilis,  especially  in  cases  not  treated  at  all,  or 
imperfectly  treated. 

It  appears  without  any  apparent  previous  lesion  of 
the  scalp,  without  desquamation,  as  well  as  without 
objective  phenomena,  such  as  pain  or  pruritus  ;  the 
fall  of  hair,  which  becomes  more  and  more  abundant, 
leads  to  the  production  of  areas  of  alopecia  scattered 
irregularly  over  the  scalp,  resembhng  the  empty 
spaces  in  a  badly  planted  wood. 

It  may  be  observed  exceptionally  in  the  beard.  It 
frequently  coincides  with  a  pigmentary  syphihde  of 
the  neck. 

This  form  of  alopecia  is  almost  pathognomonic  of 
syphiUs,  for  it  is  altogether  exceptional  in  other  general 
conditions  (tuberculosis,  convalescences  from  severe 
illnesses,  etc.)  which  cause  diffuse  loss  of  hair.  The 
bald  areas  of  alopecia  areata  are  larger  and  smoother 
than  those  of  syphihs. 

It  may,  therefore,  aid  in  the  diagnosis  of  syphihs, 
and  is  worthy  of  attention  as  it  may  be  the  first  syphiH- 
tic  manifestation  noticed  by  the  patient.  Indeed,  it  is 
not  rare  to  see  it  appear  in  subjects  who  have  had  a 
dwarf  chancre  which  healed  in  a  few  days  and  was  not 
noticed,  who,  probably,  have  not  had  any  cutaiieous 
syphilide,  and  in  whom  the  most  careful  examination 
has  only  revealed  a  few  shghtly  enlarged  Ijmiphatic 
glands  and  one  or  two  sm'all  syphihtic  plaques  of  the 
mouth. 

The  presence  of  this  alopecia  is  an  indication  for  the 
most  careful  search  for  all  the  signs  of  syphihs,  even 
the  shghtest,  and,  in  the  absence  of  any  other  sign, 
e^xamination  by  the  Wassermann  Reaction. 

Syphihtic  alopecia  generally  begins  during  the 
third  month  of  syphihs  ;  it  always  heals  without 
leaving  any  trace  behind.     It  may  heal  spontaneously, 


582  SYPHILIS   AND   THE   ABMY 

but  cure  is  hastened  by  mercurial,  and  especially  by 
arsenical  treatment,  which  is  sometimes  followed  by  a 
regrowth  of  hair  more  abundant  than  before  the 
syphilis. 

Lesions  of  the  Nails 

The  nails  may  be  attacked  during  the  course  of 
secondary  syphilis,  become  cracked,  detached,  or 
hypertrophied.  More  frequently,  after  periungual 
sjrphihdes,  swelling  of  the  bed  of  the  nail  (perionyxis) 
may  develop. 

Lesions  of  the  Mucous  Membranes 

All  lesions  developed  during  the  course  of  secondary 
syphiUs  on  the  visible  mucous  membranes  may  be 
reduced  to  two  ;  diffuse  erythematous  inflammations , 
often  transient,  seen  usually  on  the  pharynx,  and  the 
mucous  plaque. 

Wherever  situated,  the  mucous  plaque  begins  as  a 
round  lesion  with  shghtly  raised  edges  and  an  eroded, 
slightly  depressed  centre.  The  erosion,  of  variable 
extent,  is  red  and  exudative.  The  border  is  red  on 
mucous  membranes  that  are  simply  moist  ;  on  those 
of  the  digestive  tracts,  its  constant  impregnation  by 
saUva  gives  it  whitish  or  opahne  colour. 

The  configuration  of  the  parts  which  are  the  seat,  of 
mucous  plaques  modifies  their  form,  and  makes  them 
irregular  or  fissured,  especially  on  the  Hps. 

Local  irritations  and  infections  may  modify  their 
appearance  and  cause  deep  ulceration,  or  on  the 
other  hand,  hypertrophy  and  a  papillomatous  appear- 
ance (hypertrophic  mucous  plaque,  condyloma  latum). 

Lesions  of  the  Buccal  Mucous  Membrane. — Mucous 
plaques  may  occupy  different  regions  of  the  buccal 
cavity.  On  the  lips  they  are  situated  either  on  the 
commissures,  in  the  form  of  round  erosions  with  a 
raised  border  ;  they  are  rarely  hypertrophic,  except 
in  patients  who  smoke  much  and  place  the  cigarette 


SYMPTOMS  AND  DIAGNOSIS  583 

or  pipe  at  the  corner  of  the  mouth  :  or  on  the  free 
border,  in  the  form  of  round  erosions,  with  a  white 
margin,  a  deep  red  and  flat  base,  exudative  and  some- 
times covered  with  a  scab  ;  this  last  locaUsation  occurs 
almost  exclusively  in  smokers. 

On  the  internal  surface  of  the  cheeks  the  plaques  are 
usually  erosive,  round,  or  shghtly  irregular,  red  in  the 
centre  ;  the  border  and  a  more  or  le.ss  extensive  por- 
tion of  the  centre  is  often  white,  sometimes  like  silver, 
resembling  leucoplakia. 

Mucous  plaques  must  not  be  confused  with  mercurial 
stomatitis,  the  lesions  of  which  first  affect  the  gums 
but  may  also  occur  on  the  cheeks  ;  with  aphthae 
(thrush)  which  consist  of  round  plaques,  covered  with  a 
white  creamy  or  shghtly  yellow  deposit  and  evolving 
rapidly  ;  with  lesions  artificially  induced  (bums  from 
a  cigarette,  acid,  etc.),  which  are  round,  regular,  and 
covered  mth  a  white  deposit,  sometimes  detached  at 
one  part  (rupture  of  the  phlyctenule)  and  heahng 
rapidly  ;  with  the  plaques  of  leucoplakia,  which  are 
more  irregular,  more  extensive,  and  occupy  principally, 
either  the  neighbourhood  of  the  labial  commissure,  or 
that  of  the  large  molars.  This  last  diagnosis  is  of  real 
importance,  a  certain  number  of  soldiers  attacked 
by  leucoplakia,  due  to  former  syphiHs,  exploit  their 
lesions  to  gain  admittance  to  hospital,  when  there  is  no 
reason  for  this,  the  lesion  being  non-contagious. 

On  the  tongue,  mucous  plaques  often  assume  a 
special  aspect,  owing  to  the  papillary  structure  of  the 
mucous  membrane  :  they  are  round  or  oval,  clearly 
defined,  flat,  with  no  trace  of  papillae  {depapillated 
plaques).  Sometimes  they  are  erosive,  regular  or 
irregular,  surrounded  by  a  white  or  opaline  border. 

Mucous  plaques  may  be  confused  with  marginate 
exfoHative  glossitis.  This  differs  in  the  irregularity 
and  variabihty  of  its  contour,  which  has  been  com- 
pared with  that  of  a  geographical  map,  and  by  its 
white,   slightly   raised,    clearly  marked    border,   the 


584  SYPHILIS   AND   THE   ARMY 

eccentric  and  irregular  progression  of  which  extends 
from  day  to  day ;  with  leucoplakia,  which  has  been 
referred  to  above  ;  with  Wilson's  Hchen,  a  much  rarer 
and  more  persistent  affection,  the  lingual  lesions  of 
which  coincide  with  the  white  spots  on  the  mucous 
membrane  of  the  inner  surface  of  the  cheeks,  and 
\vith  very  pruriginous  cutaneous  lesions. 

Lesions  of  the  Pharynx 

These  are  of  great  frequency,  more  so  perhaps  than 
those  of  the  mouth. 

On  the  soft  palate,  they  consist  in  mucous  plaques  of 
regular  or  irregular  form,  generally  opaline,  as  if  a 
shght  coating  of  pale  grey  paint  had  been  spread  over 
the  mucous  membrane  ;  they  are  rarely  erosive.  Ih^ 
often  attain  considerable  dimensions,  forming  a  large 
surface  of  vivid  or  deep  red  on  one  or  both  of  the 
anterior  pillars,  limited  by  a  semicircular,  sHghtly 
projecting  border,  forming  a  kind  of  large  arcade 
{giant  plaques  of  the  soft  palate). 

Sometimes,  at  the  beginning  of  syphilis,,  a  diffuse 
bright  redness  is  observed. 

The  tonsils  may  be  the  seat  of  various  lesions  :  they 
are  very  often  hypertrophied,  voluminous,  irregular,  of 
almost  normal  or  reddish  colour,  and  firm  consistency, 
more  pronounced  than  in  common  tonsillar  hyper- 
trophy. The  mucous  plaques,  sometimes  opaline, 
sometimes  erosive,  are  often  very  numerous,  sometimes 
small  and  difficult  to  discover. 

In  certain  cases  the  lesions  attain  very  considerable 
development  :  the  plaques  occupy  almost  the  entire 
tonsil,  and  are  covered  by  a  thick,  greyish  white, 
adherent  deposit,  beneath  which  the  tonsillar  tissue  is 
ulcerated  and  bleeds  easily.  This  diphtheroid  form  of 
syphilitic  angina  may  be  confused  with  diphtheria, 
and  with  Vincent's  angina. 

The  last  confusion  is  the  easier  because  Vincent's 


SYMPTOMS   AND  DIAGNOSIS  585 

spirillar  infection  may  be  grafted  on  syphilitic  lesions 
of  the  tonsil,  or  coincide  with  secondary  syphilis. 

Visceral  Affections 

Secondary  syphilis  may  attack  all  the  viscera  and 
tissues  ;  I  shall  only  describe  the  most  important  of 
the  deep  locaUsations. 

Nervous  Affections  of  varying  intensity  and  gravity 
are  frequent  during  the  course  of  secondary  syphiUs. 

Headache  is  extremely  frequent,  practically^  constant 
in  untreated  syphiUs  :  sometimes  frontal,  sometimes 
occipital,  in  some  patients  it  is  so  severe  as  to  prevent 
sleep  ;  it  is  characterised  by  its  occurrence  or  exacerba- 
tion in  the  evening  or  at  night.  It  is  often,  but  not 
always,  accompanied  by  hypertension  and  lymphocy- 
tosis of  the  cerebro-spinal  fluid,  even  if  the  headache  is 
not  very  violent  ;  it  is  sometimes,  but  not  always, 
relieved  by  lumbar  puncture.  In  certain  cases  it  is 
due  to  endo-cranial  periostoses,  and  is  then  both  intense 
and  persistent. 

Grave  cerebro-meningeal  symptoms  maybe  observed 
during  the  course  of  secondary  syphilis. 

These  symptoms  assume  various  clinical  types. 

Hemiplegia,  either  preceded  or  not  by  premonitory 
signs,  such  as  difficulty  in  speech,  cerebral  fatigue,  or 
headache,  occasionally  commences  suddenly.  It  is 
established  progressively  within  a  few  hours,  soon  be- 
coming complete,  and  at  the  same  time  intellectual 
obnubilation  ends  in  more  or  less  complete  coma.  It 
may  be  followed  by  death  in  some  hours  ;  more 
frequently  the  patient  recovers,  but  is  often  left  with 
paralysis  and  contractures. 

When  affecting  the  right  side  of  the  body,  it  is  often 
accompanied  by  aphasia,  which  is  generally  curable. 

Of  all  the  nervous  manifestations  of  syphilis,  hemi- 
plegia is  the  one  most  likely  to  appear  at  an  early 
date.     It  may  precede  other  secondary  symptoms  and 


586  SYPHILIS   AND   THE   ARMY 

occur  even  in  the  first  days  of  syphilitic  evolution  : 
in  a  case  of  Millard's,  which  terminated  fatally,  the 
chancre  had  only  been  in  existence  eleven  days. 

At  the  post  mortem,  special  lesions  of  the  arteries 
at  the  base  of  the  brain  are  found,  as  well  as  meningeal 
changes. 

Facial  paralysis,  of  peripheral  type,  is  more  frequent 
than  hemiplegia  ;  it  generally  occurs  in  the  second 
or  third  month. 

Paralysis  of  the  oculo-motor  muscles  is  more  rare,  but 
may  accompany  facial  paralysis. 

These  paralyses  are  the  result  of  basal  meningitis, 
causing  compression  of  the  corresponding  nerves,  as 
it  produces  compression  of  the  optic  and  auditory 
nerves. 

The  spinal  meninges  participate  in  the  process  of 
basal  meningitis. 

Along  with  rare  cases,  manifested  by  definite  symp- 
toms of  spinal  meningitis  and  acute  meningo-myelitis , 
there  are  other  more  common  cases,  in  which  the 
meningeal  changes  are  not  revealed  by  appreciable 
objective  symptoms  ;  in  these  cases  lumbar  puncture 
shows  the  presence  of  lymphocytosis  of  the  -cerebrospinal 
fluid  and  albumen  in  this  fluid.  Ravaut  has  shown 
the  frequency  of  cerebro-spinal  lymphocytosis  in 
secondary  syphihs  and  proved  that  it  may  indicate  the 
later  development  of  serious  cerebro-spinal  lesions . 

The  sensory  organs  may  be  attacked  during  secondary 
syphilis. 

Deafness,  tinnitus,  and  vertigo  may  be  caused  by 
lesions  of  the  auditory  nerve  and  labyrinth.  These 
affections,  to  which  attention  has  been  directed  since 
the  use  of  arsenical  preparations,  were  known  of  before 
the  discovery  of  arsenobenzol,  but  appear  to  be  par- 
ticularly frequent  in  patients  treated  with  this  substance, 

Optical  lesions  are  much  more  common. 

Iritis  is  the  easiest  to  recognise,  and  the  most  apparent 
of  all  ocular  lesions  ;   it  generally  develops  between  the 


SYMPTOMS   AND   DIAGNOSIS  587 

fifth  to  the  tenth  month  after  the  chancre,  usually 
about  the  sixth  month,  sometimes  earlier,  and  must  be 
regarded  as  indicative  of  particularly  severe  syphilis. 

Generally  unilateral,  it  is  manifested  by  periorbital 
pains  of  varying  intensity,  often  slight,  by  photophobia 
and  more  or  less  pronounced  diminution  of  visual 
acuteness  as  well  as  b}^  objective  symptoms  which  any 
medical  man,  even  if  not  versed  in  practical  ophthal- 
mology, must  know  and  cannot  fail  to  recognise  :  more 
or  less  marked  pericorneal  injection,  change  in  the 
colour  of  the  iris,  which  loses  its  brilliant  appearance 
and  takes  on  a  greyish  tint,  contraction  and  immobility 
of  the  pupil,  due  to  congestion  of  the  iris  or  adhesions. 
Atropine  dropped  into  the  eye  induces  dilatation  of 
the  pupil  ;  but  if  adhesions  are  present,  the  dilatation 
is  unequal  and  the  pupil  irregular. 

Syphilitic  iritis  assumes  various  clinical  forms 
(serous  iritis,  gummous  iritis,  etc.)  into  the  details  of 
which  I  cannot  enter  here.  It  is  sufficient  for  me  to 
point  out  the  signs  by  which  it  can  be  recognised,  for 
its  gravity  is  such  that  every  syphilitic  patient  suffer- 
ing from  iritis  should  be  subjected  to  examination  by 
an  ophthalmic  surgeon. 

Agam,  iritis  frequently  accompanies  lesions  of  the 
deeper  portions  of  the  eye,  such  as  cyclitis  and  choroi- 
ditis. 

Optic  neuritis  and  retinitis  are  frequent  during  the 
secondary  period  of  syphilis,  even  at  the  beginning. 
They  are  often  unrevealed  by  any  functional  symptom, 
and  can  only  be  recognised  by  examination  of  the 
fundus  of  the  eye.  In  default  of  the  systematic 
examination  of  all  syphilitics  by  an  ophthalmologist,  a 
large  number  of  these  complications  pass  unnoticed. 
I  may  add  that  they  are  accompanied  by  lymphocytosis 
of  the  cerebro-spinal  fluid. 

Secondary  Syphilitic  Icterus  is  characterised  by  its 
appearance  in  conjunction  with  generalised  eruptions  ; 
it  is  accompanied  by  phenomena  of  biliary  retention,  but 


588  SYPHILIS  AND   THE  ARMY 

the  gastric  troubles  of  catarrhal  icterus  are  generally 
absent.  It  usually  terminates  in  recovery  without 
any  complication,  within  fifteen  to  twenty  days  ;  a 
few  rare  cases  of  grave  icterus  in  secondary  syphilis 
have  been  reported,  presenting  the  ordinary  sympto- 
matology of  this  syndrome. 

Secondary  syphilitic  icterus  would  appear  to  belong 
to  the  class  of  haemolytic  icteri,  according  to  recent 
researches,  particularly  those  of  Gaucher  and  Giroux. 

Secondary  Syphilitic  Nephritis,  apart  from  any  former 
renal  taint,  generally  occurs  in  the  third  and  eighth 
month  of  syphilis.  It  is  revealed  most  frequently  by 
sudden  and  considerable  dropsy,  and  by  albuminuria, 
which  frequently  reaches  10  to  15  grammes  daily,  some- 
times even  50  grammes.  More  or  less  pronounced 
signs  of  uraemia  may  accompany  the  dropsy  :  vomiting, 
headache,  etc.  Recovery  is  the  rule,  provided  the  patient 
is  energetically  treated,  and  as  soon  as  possible  after 
the  beginning  of  the  disease  ;  it  is  often  slow,  and  the 
albuminuria  may  persist  for  several  months. 

Finally,  I  must  mention  Phlebitis,  which  is  frequent 
during  the  secondary  period  and  often  coincides  with 
the  roseola.  It  affects  the  superficial  veins  of  the 
lower  limbs,  and  nearly  always  several  of  them  simul- 
taneously, often  those  of  both  legs.  It  is  characterised 
by  the  development  of  hard  cords,  neither  voluminous 
nor  painful,  often  indeed  painless,  and  never  gives  rise 
to  oedema  or  embolism. 

GENERALITIES   OF  TERTIARY   SYPHILIS 

There  is  no  necessity  to  describe  the  tertiary  lesions 
of  syphilis  ;  they  are  met  with  relatively  seldom  in 
military  practice,  and  have  no  special  indications, 
apart  from  the  question,  not  without  importance,  of 
the  invaliding  they  may  bring  about.  Their  treat- 
ment offers  no  particular  indication,  beyond  the  neces- 
sity, always  important  in  the  army,  of  carrying  out  as 


SYMPTOMS   AND   DIAGNOSIS  589 

actively  as  possible  the  cure  of  soldiers  who,  after 
recovery,  may  be  again  sent  to  their  unit.  Although 
certain  localisations  of  tertiary  syphilis  may  be  con- 
tagious, this  is  so  exceptional  that  there  is  never  any 
necessity  to  send  a  tertiary  syphilitic  to  hospital  when 
the  lesions  by  which  he  is  affected  do  not  interfere 
with  the  performance  of  his  military  duty,  or  do  not 
necessitate  energetic  treatment  incompatible  with  the 
obligations  of  service. 

I  must  insist  upon  this  last  point,  because  I  have 
too  frequently  seen  men  sent  to  hospital  who  were 
suffering  from  tertiary  lesions  of  the  skin  or  tongue, 
neither  ulcerated  nor  painful,  which  did  not  in  any  way 
prevent  them  from  carrying  out  their  duties,  and 
only  required  treatment  which  could  easily  be  carried 
out  with  the  unit.  Men  often  take  advantage  of  their 
disease  to  impose  on  the  medical  man. 

I  shall  only  briefly  summarise  the  principal  localisa- 
tions of  tertiary  syphilis. 

As  regards  the  skin,  syphilides  of  various  types  are 
observed,  papular,  papulo-tubercular,  ulcerous,  gum- 
matous, always  characterised  by  :  (1)  their  form,  which 
is  nearly  always  round,  or  reniform,  and  their  dis- 
position in  groups  of  more  or  less  rounded  configuration, 
and  by  centrifugal  extension  when  they  are  multiple  ; 
(2)  the  small  number  of  their  elements,  and  their 
habitual  limitation  to  one  region  of  the  body  or  to  a 
small  number  of  regions,  contrary  to  secondary  syphi- 
lides, which  are  usually  generalised  ;  (3)  the  tendency 
to  ulceration,  or,  if  they  do  not  ulcerate,  to  interstitial 
absorption  of  the  invaded  tissues  ;  hence  the  usual 
persistence  of  indelible  cicatrices,  often,  but  not  always, 
surrounded  by  a  zone  of  pigmentation  ;  (4)  the  absence 
of  functional  phenomena,  pruritus,  and  pain,  except 
when  there  is  ulceration,  and  often  even  when  they  are 
situated  in  the  neighbourhood  of  orifices  and  in  very 
mobile  regions. 

The  diagnosis  of  tertiary  syphilitic  lesions  rests  on 


590  SYPHILIS   AND   THE   ARMY 

these  characteristics :  on  the  former  existence  of 
recognised  syphilitic  affections  (it  must  be  borne  in 
mind  that  syphilitic  antecedents  are  frequently  absent, 
less  often,  however,  in  a  man  than  a  woman),  on  the 
verification  of  syphilitic  stigmata,  cutaneous  cica- 
trices, .Argyll  Robertson  sign,  abolition  of  the  tendon 
reflexes,  on  the  existence  of  a  positive  Wassermann 
Reaction  ;  in  doubtful  cases,  rapid  recovery  by  mer- 
curial, arsenical,  or  iodide  treatment  may  settle  the 
diagnosis. 

The  most  frequent  lesions  of  the  accessible  mucous 
membranes  are  ulcerations  and  sclero-gummatous  lesions 
of  the  tongue,  with  or  without  leucoplakia,  or  at  least 
certain  of  its  forms,  for  it  would  be,  at  the  present  time, 
excessive  to  state  that  leucoplakia  is  always  caused  by 
syphilis  ;  ulcerous  lesions  of  the  soft  palate,  leading 
generally  to  rapid  perforation,  and  which  it  is  neces- 
sary to  treat  very  actively  from  the  beginning. 

The  visceral,  arterial,  cardiac,  nervous,  hepatic,  and 
other  lesions,  which  constitute  an  important  part  of 
internal  pathology,  need  not  be  described  here. 


CHAPTER    V 

TREATMENT   OF    SYPHILIS 

THE    SPECIAL    CONDITIONS   OF    THE    TREATMENT 
OF   SYPHILIS  IN  THE  ARMY 

The  anti-syphilitic  medicaments  may  be  reduced  to 
three  substances-^-mercury,  iodine,  arsenic ;  but  the 
methods  of  administration  and  the  preparations  of  these 
three  substances  are  numerous.  Each  syphilologist 
has  made  a  choice  amongst  these  preparations,  and  laid 
down  special  rules  for  their  application,  which  seem  to 
him  to  respond  best  to  the  therapeutic  indications  of 
syphilis.  Thus,  he  has  evolved  an  elective  type  of 
syphilitic  treatment  which  he  habitually  employs  ;  but, 
if  he  has  the  medical  spirit,  he  knows  how  to  deviate 
from  this  type  and  modify  it,  according  to  the  indica- 
tions of  each  case,  as  well  as  to  the  social  condition 
of  the  patients. 

The  conditions  of  military  life,  more  especially  those 
of  the  present  war,  introduce  special  indications  and 
choice  of  treatment,  which  military  surgeons  and 
syphilologists  must  take  into  account.  In  default  of 
this  adaptation  to  military  conditions,  the  doctor  will 
meet  with  great  difficulties,  sometimes  the  formal 
opposition  of  the  staff  to  the  execution  of  the  treat- 
ment he  prescribes  :  indeed,  he  may  cause  a  useless 
reduction  of  effectives  and  cripple  the  necessities  of 
national  defence. 

591 


593  SYPHILIS   AND   THE  ARMY 

Let  us  first  consider  the  special  indications  in  the 
army  during  the  present  war. 

In  the  case  of  combatant  soldiers  at  the  Front,  men 
remaining  at  the  depots,  or  employed  in  the  interior, 
especially  men  in  munition  works,  attacked  by  a  con- 
tagious disease  of  any  kind,  it  is  necessary,  in  the  first 
place,  to  put  them  out  of  the  way  of  doing  harm  to 
others  by  transmission  of  their  disease.  On  the  other 
hand,  they  must  be  rendered  fit  for  service  in  their 
companies  or  workshops  as  soon  as  possible,  and  the 
evil  effects  resulting  from  their  disease  must  be  re- 
reduced  to  a  minimum. 

In  the  case  of  syphilis,  these  necessities,  indicate 
two  precepts  : 

(1)  Cause  the  disappearance,  by  the  most  energetic 
treatment  possible  of  contagious  lesions,  which,  for- 
tunately, develop  on  surfaces  accessible  to  direct 
examination,  and  may,  consequently,  be  recognised 
and  watched. 

(2)  When  the  contagious  Jesions  are  healed,  the 
treatment  should  be  continued,  less  energetically  than 
at  first,  but  sufficiently  to  protect  the  man  from  later 
contagious  lesions  and  the  different  manifestations  of 
the  disease,  by  processes  which  do  not  hinder  his  mili- 
tary duties  from  being  carried  out. 

Certainly,  the  problem  would  be  solved  in  its  entirety, 
if  one  knew  of  a  sure  and  rapid  method  of  sterilising 
syphilis  by  medicamental  or  bio  therapeutic  treatment. 
Despite  the  somewhat  incautious  pretensions  held  out 
by  Ehrlich  on  the  action  of  arsenobenzol,  the  problem 
has  not  been  solved  ;  I  shall  show  later  what  one  must 
think  about  this  subject. 

We  must,  therefore,  content  ourselves  with  the 
measures  at  our  disposal  to  do  the  best  we  can,  under 
somewhat  contradictory  conditions,  to  deal  with  the 
problem  of  the  treatment  of  syphilis  in  the  Army. 

In  order  to  determine  these  measures  and  their 
application,  it  is   necessary  to  find  out  what  can  be 


TREATMENT  OF   SYPHILIS  593 

expected  of  the  different  antisyphilitic  agents  and  their 
various  modes  of  employment. 

I  will  first  of  all  eliminate  iodine  and  its  different  com- 
pounds, iodide  of  potassium  and  of  sodium,  tincture  of 
iodine,  organic  preparations  of  iodine,  etc.  All  these 
agents  have  their  proper  place  in  the  antisyphilitic 
arsenal ;  but,  with  the  exception  of  mercurial  iodides, 
which  will  be  studied  with  the  mercurial  compounds, 
their  place  is  in  the  background.  They  are  almost 
entirely  without  action  on  the  sterilisation  of  syphilis, 
on  its  first  manifestations,  or  its  various  contagious 
lesions,  and,  in  any  case,  cannot  be  considered  in  the 
primary  or  secondary  periods,  either  as  active  agents 
of  treatment  or  as  having  a  prophylactic  action  on 
subsequent  complications.  It  is  during  the  course  of 
the  tertiary  manifestations  that  they  have  a  real  value 
in  the  treatment  of  gummatous  or  ulcero-gummatous 
syphilides  of  the  skin  and  mucous  membranes,  or  on 
the  cardio-vascular  lesions,  so  common  in  syphilis. 
But  tertiary  lesions  are  beyond  the  scope  of  this 
study. 

There  remain,  then,  mercury  and  arsenic. 

MERCURY 

As  'regards  syphilitic  therapy  in  the  Army,  there  is 
one  point  of  great  importance.  This,  is  the  mode  of 
administration  of  medicaments. 

The  conditions  for  supplying  bodies  of  troops  and 
medical  centres  with  drugs,  for  distributing  these  to  the 
patients,  and,  in  the  case  of  prolonged  treatment  for 
which  the  soldier  cannot  present  himself  daily  at  the 
hospital,  the  necessity  of  his  being  able  to  take  his 
supply  of  drugs  with  him  ;  the  advantage  there  is  in 
men,  and  especially  officers,  being  treated  in  more  or 
less  secrecy,  are  some  of  the  principal  considerations 
which  must  guide  the  military  surgeon  in  his  selection 
of  the  method  of  treatment — apart  from  the  special 
action  and  form  of  the  drugs. 


594  SYPHILIS  AND   THE   ARMY 

I  shall,  therefore,  consider  successively  : 

(1)  Mercurial  medication  by  ingestion  (solution, 
syrups,  pills,  tabloids,  cachets)  ; 

(2)  Mercurial  medication  per  rectum  (suppositories) ; 

(3)  So-called  endermic  mercurial  medication  (rub- 
bings) ; 

(4)  Intramuscular  mercurial  medication  (injections 
of  soluble  and  insoluble  preparations)  ; 

(5)  Intravenous  mercurial  medication. 

Mercurial  Medication  by  Ingestion 

{a)  Solutions  and  Sjrrups. — These  two  pharmaceu- 
tical forms  are  absolutely  inapplicable  at  the  front,  by 
reason  of  the  difficulties  there  would  be  in  supplying 
the  regimental  hospitals,  and  the  impossibility  of 
transporting  the  liquids. 

In  medical  centres  in  the  interior  there  would  still 
be  the  inconvenience  of  manipulation  of  large  quanti- 
ties of  liquids. 

Although  the  absorption  of  a  drug  in  solution  is 
more  regular  than  in  the  form  of  pills,  these  or  tabloids 
completely  replace  the  solutions. 

However,  in  some  oases — especially  of  tertiary 
lesions,  which  are  rarely  observed  in  the  Army  and  are 
beyond  the  scope  of  this  study — van  Swieten's  * 
Liquor  in  smaU  doses,  according  to  Brocq's  method 
(five  cubic  centimetres  administered  four  to  six  times 
daily)  is  better  than  treatment  by  pills. 

With  regard  to  mercurial  syrups,  of  whatever  kind, 
there  is  no  reason  to  use  them  in  the  Army.  Gibert's 
syrup,  the  best  known  and  most  used  among  them, 
is  a  bad  preparation,  often  causing  gastralgia  ;  its 
dosage    in    iodide    of    potassium    is     insufficient    for 

*  Van  Swieten's  Liquor,  a  solution  of  sublimate  in  a  thousandth 
part,  is  given  in  the  Formulaire  fharmaceutique  dee  hopiiaux  mili- 
taires,  and  the  preparation  is  prescribed  without  alcohol. 


TREATMENT  OF   SYPHILIS  595 

carrying  out  mixed  treatment  with  iodide  and 
mercury.* 

(6)  Pills,  tabloids,  cachets. — For  a  long  time,  pill& 
have  been  the  form  in  which  drugs  are  most  used  in  the 
treatment  of  syphilis  :  "  Treatment,  easy  to  carry  out 
in  secret,  even  when  travelling,"  according  to  the  well- 
known  formula. 

They  have  the  great  advantage  of  being  easily  taken 
about  and  of  keeping  a  fairly  long  time,  and  are  con- 
sequently capable  of  being  stocked  in  all  hospitals 
and  medical  centres.  They  can  be  given  to  men  for 
continuous  and  prolonged  treatment  without  obliging 
them  to  report  frequently  to  the  doctor.  They  must 
be  well  prepared,  the  pill  mass  should  be  soft,  with  a 
sufficient  quantity  of  glycerine  added  to  prevent  desic- 
cation. When  hard  as  stones,  as  they  are  sometimes, 
they  pass  through  the  digestive  tract  undissolved  and 
are  rejected  without  doing  more  than  simulate  treat- 
ment. 

The  Formulaire  pharmaceutique  des  hopitaux  mili- 
taires  mentions  no  other  mercurial  pills,  except  those  of 
protoiodide  of  mercury. 

The  formula  is  as  follows  : 

Protoiodide  of  mercury  .  .  .  .  .  2  gr.  50 

Powdered  opittm      .  .  .  .  .  .  1   ,, 

Powdered  liquorice  .  .  .  .  .  .  2  ,, 

Extract  of  juniper  ,  .  .  .  .  .  Q.8. 

D.  in  100  pills. 

Each  pill  contains  25  milligrammes  of  protoiodide  of 
mercury,  a  very  judicious  dosage,  which  enables  the 

*  Gibert's  Syrup  is  given  in  the  Formulaire  pharmaceutique  des 
hopitaux  militairea  under  the  name  of  mercuric  iodide.  Its  com- 
position is  as  follows : 

Mercuric  iodide        ....••!  g*"- 

Iodide  of  potassium         .  .  .  ■  .        50   ,, 

Distilled  water         .  .  .  .  .  .        50  „ 

Simple  syrup  ....••      900  ,, 

Therefore,  per  20  gr.  it  contains  a  centigramme  of  mercuric  iodide 
and  50  centigrammes  of  iodide  of  potassium. 


596  SYPHILIS  AND   THE   ARMY 

daily  dose  to  be  graduated  according  to  the  tolerance 
of  the  patients,  and  far  preferable  to  the  dosage  of 
5  centigrammes  in  Ricord's  pills. 

The  difficulty  of  this  formula  is  to  supply  pills  which 
dissolve  easily  when  they  have  been  prepared  a 
certain  time.  Medical  men  must,  therefore,  be  careful 
to  renew  their  supplies  at  sufficiently  short  intervals, 
without  waiting  for  the  period  of  quarterly  supply  for 
drugs. 

When  patients  wish  to  pay  themselves  for  their 
supply  of  protoiodide  pills,  it  will  be  better  to  give 
them  the  following  prescription  for  a  soft  pill  : 

Protoiodide  of  mercury  .  .  .  .  .25  mgr. 

Extract  of  thebaine        .....        1  cgr. 
Glycerine  excipient  .  .  .  .  .     Q.8. 

Protoiodide  of  mercury  is,  par  excellence,  the  drug 
for  secondary  syphilis  :  its  renown  for  this  period  is 
universal.  It  has  the  advantage  of  being  tolerated 
by  the  stomach,  but  produces  salivation  more  easily 
than  sublimate. 

The  usual  dose  of  protoiodide  to  be  prescribed  daily 
is  10  centigrammes  ;  this  represents  four  pills  to  be 
taken  four  times  daily,  after  meals. 

Certain  patients  cannot  tolerate  protoiodide  welt, 
in  which  case  another  mercurial  salt  must  be  given. 
The  best  is  sublimate,  the  basis  of  Dupujiiren's  famous 
pills. 

Sublimate  pills  do  not  figure  in  the  Formulaire  des 
hopitaux  militaires,  and  so  are  not  supplied  in  quanti- 
ties to  regimental  hospitals  :  they  can  only  be  made 
up  in  medical  centres  provided  with  a  chemist,  or  from 
prescriptions  made  up  by  a  civil  chemist. 

The  simplest  formula  is  the  following : 

Corrosive  sublimate    .  .  .  .  \  «». 

Extract  of  thebaine    .  .  .  .  j  one  centigramme 

Glycerine  excipient     .  .  .  •  Q-^- 

for  a  soft  pill. 


TREATMENT  OF   SYPHILIS  597 

Usual  daily  dose  :  2  pills,  i.e.  2  centigrammes  of 
sublimate. 

Sublimate  is  generally  tolerated  well  by  the  gums,  but 
often  causes  gastric  pains  or  diarrhoea  ;  it  may  be  useful 
then  to  increase  the  dose  of  extract  of  thebaine  in  the  pills. 

Compressed  tabloids  are  used  too  rarely  for  the 
administration  of  mercury.  They  have  the  advant- 
age of  pills,  in  dissolving  easily  and  completely. 

The  Central  Pharmacy  for  Military  Hospitals  sup- 
plies tabloids  containing  0*025  gr.  of  protoiodide  of 
mercury  for  the  use  of  regimental  infirmaries  and  medical 
centres,  which  can  be  used  in  the  place  of  pills.  I 
believe  that  these  tabloids  are  now  being  supplied. 

Cachets  are  rarely  employed  as  a  medium  for  the 
administration  of  mercury.  A  few  years  ago,  Alex. 
Renault  recommended  them  for  this  purpose,  and  they 
constitute  an  improvement  on  mercurial  pills  :  the 
rapid  and  complete  absorption  of  the  drug  is  assured 
by  this  form,  which  can  be  easily  transported  and 
only  necessitates  more  careful  packing. 

Mercurial  cachets  are  not  entered  in  the  nomencla- 
ture of  drugs  supplied  by  the  Central  Pharmacy  for 
Military  Hospitals. 

All  men  in  a  position  to  bear  the  expense,  especially 
officers,  who  prefer  them  to  pills  because  they  are  less 
compromising,  can  procure  them  at  their  own  cost. 

Protoiodide  of  mercury  is  the  only  mercurial  salt 
suitable  for  administration  in  cachets  ;  if  sublimate 
were  introduced  undissolved  into  the  stomach  there 
would  be  a  risk  of  causing  erosions  or  chemical  ulcera- 
tions ;  calomel  is  unsuitable,  owing  to  its  somewhat 
irregular  action,  and  its  transformation  into  sublimate 
under  the  influence  of  certain  foods. 

The  following  is  Alex.  Renault's  formula  for  cachets : 

Protoiodide ■'bl  mercury      .  .  .  .5  cgr. 

Powdered  opiiim        .  .  .  .  .      1  or  2  c»r. 

Powdered  cinchona     .....      Q.8. 

to  fill  a  small  25  centigrammes  cachet. 


598  SYPHILIS  AND   THE  ARMY 

He  prescribes  4  per  day,  i.e.  20  centigrammes  of 
protoiodide  of  mercury. 

I  prefer  using  cachets  with  a  dosage  of  half  the 
quantity,  i.e.  25  milligrammes  of  protoiodide,  and  not  to 
exceed  the  daily  amount  of  10  centigrammes  of  this  salt. 

The  various  modes  of  administration  of  mercury  by 
the  mouth,  together  with  mercurial  inunction,  were  for 
a  long  time  the  only  means  of  treating  syphilis. 

Although  they  have  a  real  action  o^  sjmhilis,  and 
especially  on  secondary  troubles,  it  is  acknowledged 
that  this  action  is  weak  and  in  no  way  comparable  to 
that  of  the  drugs  which  will  be  considered  later  on. 

They  cannot  in  any  way  be  used  to  attack  the 
disease  at  its  onset,  bring  about  the  abrupt  cicatrisa- 
tion of  chancre,  or  the  rapid  cure  of  mucous  plaques. 

They  must,  therefore,  never  enter  into  the  initial 
treatment  of  syphilis,  in  the  intensive  treatment  given 
in  hospital  for  sterilising  contagious  symptoms. 

But  they  have  a  real  value  as  a  means  of  continuous 
and  prolonged  mercurialisation,  after  cure  of  the 
contagious  troubles,  as  a  means  of  maintaining  treat- 
ment by  Fournier's  '*  intermittent  cure." 

As  men  can  carry  them  easily,  or  renew  their  stock 
when  exhausted,  pills,  tabloids,  and  cachets  should 
be  prescribed  for  them  when  they  are  leaving  the 
hospital,  after  they  have  been  subjected  to  intensive 
treatment,  and  when  they  require  treatment  for  some 
non-contagious  manifestation,  compatible  with  the 
continuation  of  their  military  service. 

If  the  various  ways  of  buccal  mercurial  administra- 
tion have  the  advantage  of  avoiding  the  necessity  of 
the  patient's  frequent  visits  to  the  doctor,  they  have, 
on  the  other  hand,  the  disadvantage  of  removing  him 
from  direct  medical  supervision.  Here,  it  is  necessary 
to  rely  on  the  patient  to  attend  to  himself  regularly. 
The  doctor  must  warn  him  not  to  neglect  the  ingestion 
of  the  pills  or  cachets. 


TREATMENT  OF   SYPHILIS  599 

With  regard  to  the  general  cure  of  syphilis,  I  shall 
indicate  the  progress  of  treatment  by  pills  later  (see 
page  146). 

Mercurial  Medication  per  Rectum 

Rectal  mercurial  medication  by  means  of  suppositories 
is  but  rarely  used,  too  seldom  in  fact. 

Recommended  by  Charles  Audry  (Toulouse)  it  is  well 
borne,  and  but  rarely  gives  rise  to  local  trouble  ;  it  has 
the  great  advantage  of  protecting  the  upper  digestive 
tracts  in  patients,  numerous  amongst  colonial  troops, 
whose  stomach  and  small  intestine  cannot  tolerate 
mercury  administered  by  ingestion.  With  these 
patients,  as  with  gastropaths  in  general,  it  replaces 
subcutaneous  and  intramuscular  injections  of  mercury 
which,  as  we  shall  see,  are  not  often  applicable  to 
syphilis  in  the  army. 

Mercurial  suppositories  cannot  be  kept  as  long  as 
pills,  necessitate  more  careful  preparation,  much  more 
complicated  packing,  take  up  a  little  more  room,  are 
more  expensive  than  pills,  and  finally  are  not  included 
in  the  Pharmaceutical  Formulary  for  Military  Hospitals ; 
so  that  they  can  only  be  used  by  soldiers  under  treat- 
ment in  certain  medical  centres,  or  who  are  able  to 
buy  them. 

Their  indications  are  almost  similar  to  those  of 
mercurial  cachets,  with  this  difference  that  they  are 
suitable  for  patients  suffering  from  lesions  or  gastric 
troubles,  but  their  use  is  not  always  compatible  with 
the  promiscuousness  of  camp  life. 

It  would  be  well,  however,  under  suitable  conditions, 
to  employ  them  more  largely  than  has  hitherto  been  the 
case,  especially  for  officers,  and  I  have  sometimes 
found  them  beneficial. 

Audry  *   recommends   suppositories   prepared   with 

*  Ch.  Audry:  "Preliminary  note  on  the  administration  of 
merciiry  per  rectvim,"  Annalea  de  dermatologie,  October  9th,  1905, 
p.  703 ;  "  Treatment  of  syphilis  per  rectmn,"  Annates  de  derma- 
tologie, March  1906,  p.  231. 


600  SYPHILIS   AND   THE   ARMY 

40%  grey  oil.  The  daily  dose  of  metallic  mercury  suit- 
able for  the  treatment  of  syphilis  in  an  adult  per  rectum 
being  3  centigrammes,  the  suppositories  are  prepared 
in  the  following  way  : 

Grey  oil,  40%      .  .  .  .  .       "  .     gr.  0075 

Cacao  butter         .  .  .  .  .  .     4  gr. 

Melt  the  cacao  butter,  let  it  cool  again,  and  when  it 
begins  to  lose  its  transparency  mix  rapidly  with  the 
grey  oil  and  pour  into  the  mould. 

Endermic  Administration 

Mercurial  inunction,  for  long  the  classical  process,  is 
to-day  practically  abandoned.  This  is  not  the  place 
to  discuss  whether  it  should  be  re-established. 
Indeed,  it  appears  to  me  to  be  completely  useless  in 
army  practice.  The  difficulty  the  men  would  have  in 
carrying  it  out  in  camp,  the  impossibility  of  their 
taking  baths,  the  dirtiness  of  mercurial  ointment  and 
soiling  of  their  clothes  prohibit  its  employment  in 
the  army  zone.  In  the  medical  centres  the  difficulties 
are  almost  the  same,  and  inexperienced  orderlies  are 
often  entrusted  with  the  rubbings,  which  require  a 
certain  amount  of  practice  to  be  done  well,  and  are 
liable  to  cause  severe  stomatitis. 

Moreover,  whatever  one's  opinion  may  be  of  the 
therapeutic  value  of  mercurial  inunction,  it  is  unsuitable 
both  for  the  intensive  treatment  at  the  onset  of  syphilis 
and  the  continuation  of  treatment  afterwards,  and, 
even  in  times  of  peace,  its  indications  are  limited. 

Intramuscular  Administration  of  Mercury  * 

Two  series  of  mercurial  preparations  may  serve 
for  the  intramuscular  treatment  of  syphilis  ;    the  one 

*  I  say  intentionally  intramuscular  and  not  subcutaneous,  because 
I  consider  that  all  mercurial  injections,  whether  of  soluble  or  in- 
soluble preparations,  should  be  made  into  the  muscle,  and  not  in 
the  subcutaneous  tissue  as  some  authors  advise. 


TREATMENT  OF   SYPHILIS  601 

insoluble,  the  other  soluble.  The  frequency  of  the 
injections,  their  effects,  and  administration  differ 
essentially,  according  to  which  series  is  employed.* 

(a)  Injections  of  Insoluble  Preparations. — Insoluble 
mercurial  injections  have  the  advantage  of  introducing 
into  the  muscular  tissue  a  relatively  large  quantity  of 
mercur}^  which,  under  the  influence  of  chemical  re- 
actions produced  by  substances  in  solution  in  the  blood 
and  plasma,  dissolve  gradually  and,  by  therapeutic 
action  taking  place  at  regular  intervals,  really  con- 
stitute a  continuous  and  regular  treatment.  The 
mercurial  reserve  deposited  in  the  muscles  is  calculated 
in  such  a  way  that  its  solution  and  absorption  are 
sufficiently  advanced  at  the  moment  the  next  injection 
is  given. 

In  practice,  the  injections  are  made  at  intervals  of 
a  week,  which  enables  the  patient  to  regulate  his 
visits  to  the  doctor. 

As  a  corollary  to  this  advantage,  there  is  the  incon- 
venience, more  theoretical  than  real,  of  exposing  the 
patient  to  an  overdose  of  mercury,  when  the  solution 
of  the  mercury  is  too  rapid. 

If  certain  rules  are  ignored,  the  injections  might 
cause  the  deposit  of  too  large  a  quantity  of  mercury 
in  the  tissues  ;  the  patient  could  not  be  relieved  of 
this  surplus  of  mercury,  or  only  with  difficulty  by 
surgical  intervention,  if  the  phenomena  of  mercurial 
intoxication  developed  ;  hence  the  possibility  of  grave 
accidents,  even  death. 

As  a  matter  of  fact,  the  dangers  of  insoluble  mer- 
curial injections,  of  which  some  medical  men  have  un- 
justly made  a  scare,  are  practically  non-existent :  in 
all,  or  nearly  all,  the  fatal  cases,   reported  in  their 

*  Some  soldiers  may  be  tempted,  on  accovmt  of  the  pain,  to 
escape  treatment  by  intramuscular  or  intravenous  injections.  A 
judgment  of  the  War  Covmcil,  dated  September  7th,  1916,  con- 
demned a  soldier  to  three  months'  imprisonment  for  having  refused 
to  submit  to  an  intramuscular  injection  prescribed  by  the  medical 
man  in  attendance. 


602  SYPHILIS  AND   THE  ARMY     . 

entii'ety,  some  error  is  revealed  :  the  doses  of  mercury 
have  been  too  high,  the  injections  too  close  together, 
and,  above  all,  these  have  been  continued  when  signs 
of  mercurial  intoxication,  especially  stomatitis,  have 
already  appeared.  These  phenomena  should  have 
caused  the  suspension  of  the  injections. 

These  accidents  have  been  observed  specially  with 
grey  oil.  Now,  for  twenty-five  years  I  have  made,  or 
caused  to  be  made,  more  than  60,000  injections  of  grey 
oil  and  have  only  seen  two  of  my  patients  succumb. 
In  one  of  these  the  injections  had  been  continued  by 
error,  after  the  appearance  of  stomatitis.  The  other 
died  after  the  untimely  extraction  of  twelve  or  fourteen 
dental  stumps  at  one  sitting,  during  the  course  of  treat- 
ment, which  was  followed  by  extensive  necrosis  of  the 
jaw. 

A  more  justifiable  objection  may  be  raised  to  in- 
soluble intramuscular  injections — the  pain  they  some- 
times cause.  This  is  often  severe  after  injections  of 
calomel,  but  is  generally  absent  after  injections  of  grey 
oil,  provided  it  is  well  prepared  and  a  sufficiently  fine 
needle  is  used.  Nevertheless,  pain  may  be  produced 
after  piercing  a  nervous  filament,  and,  as  the  injection 
is  made  in  the  gluteal  muscles,  this  may  impede 
walking.  Sometimes  the  pain  following  injections  of 
grey  oil  may  result  from  the  development  of  an  inflam- 
matory nodule  in  the  subcutaneous  cellular  tissue  or 
in  the  muscle  ;  it  then  appears  on  the  third  or  fourth 
day  and  subsides  in  about  a  week.  It  is  altogether 
exceptional  for  the  nodules  to  suppurate,  and,  when 
suppuration  appears,  spontaneous  opening  or  an 
incision  results  in  rapid  recovery. 

The  sole  possibility  of  pain,  of  the  unfitness  of  the 
man — pain  which  may  be  more  or  less  real,  which  some 
soldiers  may  exaggerate  and  even  make  a  pretext  for 
discharge  from  duty — suffices  to  show  that  insoluble 
injections  cannot  be  used  in  the  treatment  of  syphilis 
at  the  Front. 


TREATMENT  OF   SYPHILIS  603 

Grey  oil  has  an  activity  inferior  to  that  of  cyanide 
of  mercury  in  intravenous  injections,  but  equal  or 
superior  to  that  of  the  majority  of  soluble  intramuscular 
injections  ;  it  is  of  very  practical  use  in  the  continuation 
of  treatment.  The  injections,  made  in  doses  which  will 
be  indicated  later  on,  once  a  week  in  a  series  of  six  to 
eight,  every  three  or  four  months,  constitute  sufficient 
medication,  after  intensive  treatment  at  the  onset. 
The  doctor  is  sure  an  injection  has  been  made,  he  is 
not  always  sure  that  a  pill  has  been  taken  and  swallowed; 
neither  he  nor  the  patient  is  too  busy  for  a  weekly 
injection. 

Calomel  in  intramuscular  injections  is  one  of  the 
most  active  mercurial  preparations  ;  it  is  specially 
indicated  in  refractory  localisations  of  tertiary  syphilis 
in  the  tongue  or  brain.  But  the  injection  often 
causes  acute  pain  ;  appearing  on  the  third  or  fourth 
day,  it  reaches  its  maximum  on  the  fifth  or  sixth,  and 
is  often  sufficient  to  prevent  the  patient  walking.  It 
persists  for  three  or  four  days,  leaving  behind  it  pain- 
fulness  in  the  gluteal  region. 

Injections  of  basic  salicylate  of  inercury  and  yelloiv 
oxide  of  mercury,  less  used  than  calomel,  have  the  same 
inconveniences. 

Finally,  these  three  preparations,  as  well  as  grey  oil, 
are  not  suitable  for  the  treatment  of  syphilis  at  the 
Front.  They  may  be  employed  in  medical  centres, 
on  patients  suffering  from  grave  lesions,  removed  from 
active  service  for  some  time  by  illness  or  wounds. 

The  grey  oil  mentioned  in  the  Formulaire  pharma- 
ceutique  des  hopitaux  militaires  is  that  of  the  Codex, 
containing  40^{)  of  mercury  ;  100  cubic  centimetres 
contain  : 

Pmified  meretiry  .  .  ,.  .40  gr. 

Sterilised  anhydrous  lanoline    .  .  .  .     26    ,, 

Sterilised  oil  of  vaseline  .  .  .    about  60    ,, 

Prepared  with  the  necessary  care,  on  which  I  need 


604  SYPHILIS   AND   THE  ARMY 

not  insist  here,  it  should  be  homogeneous  in  appearance, 
and,  under  the  microscope,  only  reveal  minute  grains 
of  mercury. 

The  weekly  injection  of  grey  oil  is  made  with  a  dose 
of  seven  to  eight  centigrammes  of  mercury,  which 
corresponds  to  three  and  a  half  or  four  divisions  of  a 
Pravaz  syringe  of  one  cubic  centimetre  capacity. 
When  making  injections  of  grey  oil,  it  is  necessary  to 
use  very  accurately  marked  syringes  ;  the  rod  of  the 
piston  should  have  an  index,  so  as  to  avoid  the  correct 
dose  being  exceeded. 

Calomel  oil  appears  in  the  Formulaire  pharmaceutique 
des  hopitaux  militaires  with  the  following  composition  : 

Calomel  .......  5  gr. 

Sterilised  anhydrous  lanoline  .  .  .  .        16    ,, 

Sterilised  vaseline  oil      .  .  .  .  .      100  ccin. 

I  prefer  the  following  formula,  which  causes  less 
pain  : 

Calomel  washed  in  alcohol      .  .  .  5  or  10  gr. 

Sterilised  sweet  oil  of  almonds         .  .      100  gr. 

The  oil  should  be  thoroughly  shaken  before  being 
introduced  into  the  syringe. 

The  quantity  of  liquid  injected  must  be  calculated  in 
such  a  way  as  to  introduce  5  to  10  centigrammes  of 
calomel  into  the  muscle. 

The  injections  are  repeated  once  a  week,  not  exceed- 
ing four  or  six  injections  in  a  series. 

Insoluble  injections  must  be  made  in  the  muscle, 
with  the  precautions  which  will  be  indicated  later 
when  describing  the  technique  of  intramuscular  injec- 
tions (see  p.  607). 

(b)  Injections  of  Soluble  Preparations. — Numerous 
soluble  mercurial  preparations  have  been  proposed  for 
the  treatment  of  syphilis  by  means  of  injections.  A 
few  only,  which  I  shall  enumerate  farther  on,  have 


TREATMENT   OF   SYPHILIS  605 

been  retained,  owing  to  their  activity  and  tolerance 
by  the  tissues. 

In  a  general  way,  the  activity  of  these  preparations 
does  not  vary  very  considerably  from  one  to  another, 
on  condition  that  they  are  employed  in  comparable 
doses.  This  activity  is  inferior,  on  the  one  hand,  to 
that  of  intravenous  injections,  and,  on  the  other,  to 
that  of  calomel  injections.  It  is  still  more  inferior 
to  that  of  arsenical  preparations. 

Therefore  it  is  impossible,  with  any  of  these  soluble 
preparations,  to  carry  out  the  intensive  cure  of  syphilis, 
which,  at  the  present  time,  is  a  strict  obligation  at  the 
period  of  chancre  or  of  secondary  symptoms.  I  myself 
have  seen  too  many  syj)hilitics  who,  after  being  in 
hospital  for  a  chancre  for  two  or  three  months,  and 
having  received  from  forty  to  ninety  soluble  mercurial 
injections  during  this  time,  have  hardly  been  discharged 
before  they  are  admitted  to  another  hospital  with  an 
eruption  of  generalised  syphilides,  or  a  crop  of  mucous 
plaques  on  the  mouth. 

Soluble  intramuscular  injections  have  the  advantage 
over  insoluble  injections  of  not  exposing  the  patient 
to  the  danger  of  mercurial  accumulation.  I  have 
already  shown  that  these  dangers  are  in  reality  very 
small  with  a  careful  technique. 

They  are  not  often  painful,  but  here  again  distinc- 
tion must  be  made  between  the  preparations  :  those 
which  have  the  reputation  of  being  painless,  like 
mercuric  benzoate,  are  painful  if  the  needle  touches  a 
nerve  ;  they  may  even,  if  not  injected  deeply  and  with 
care,  produce  nodules  and  abscesses,  which  are  often 
very  painful. 

Compared  with  injections  of  insoluble  preparations, 
those  of  soluble  preparations  have  the  disadvantage  of 
requiring  the  patient  to  attend  for  treatment  three  to 
six  times  a  week,  whereas  an  injection  of  grey  oil  is 
only  made  once  a  week. 

In  short,  intramuscular  injections  of  soluble  prepara- 


606  SYPHILIS   AND   THE   ARMY 

tions  are  unsuitable  for  the  intensive  treatment  of 
■syphilis,  and  in  later  treatment  they  require  too 
frequent  visits  to  the  doctor.  The  pain  they  may 
cause,  moreover,  renders  them  unsuitable  for  men 
engaged  in  active  service,  especially  those  who  are 
serving  at  the  Front. 

Hence,  their  applications  in  war  practice  are  very 
limited  ;  they  are  reduced  to  the  treatment  of  syphili- 
tics  who,  in  hospital  for  some  cause,  apart  from  syphilis, 
nevertheless  require  mercurial  treatment  more  active 
than  by  pills,  or  those  who  do  not  tolerate  these,  or 
men  whose  veins  are  not  prominent  enough  for  intra- 
venous injections. 

The  solutions  for  intramuscular  injections,  given  in  the 
Formulaire  pharmaceutique  des  hopitaux  militaires, 
are  the  following  : 

(1)  Solution  of  benzoate  of  mercury. 

Benzoate  of  mercury  .  .  .  .      1   gr. 

Pure  chloride  of  sodium         .  .  .  .0*75  gr. 

Sterilised  distilled  water         ....      100  ccm. 

This  solution  contains  1  centigramme  of  benzoate  of 
mercury  per  cubic  centimetre. 

It  is  injected  in  a  dose  of  1  cubic  centimetre  daily  or 
every  other  day. 

(2)  Aqueous  solution  of  hiniodide  of  mercury. 


Biniodide  of  merciu-y    . 
Iodide  of  sodium 
Xeutral  phosphate  of  sodium 
Pure  chloride  of  sodium 
Sterilised  distilled  water 


0  50  gr. 

0  50  gr. 

1  gr. 
0-35  gr. 
50  ccm. 


This  solution  contains  one  centigramme  of  biniodide 
of  mercury  per  cubic  centimetre,  corresponding  to 
0  044  gr.  of  metallic  mercury. 

(3)  Oily  injection  of  hiniodide  of  mercury. 

Iodide  of  mercury  .  .  .  .  .     0  20  gr. 

Guaiacol         .  .  .  .  .  .  ,     0  10  gr. 

Purified  and  distilled  olive  oil         ,  ,  .     46  gr. 


TREATMENT  OF  SYPHILIS  607 

Cyanide  of  mercury,  which  has  been  recommended, 
has  to  be  discarded,  owing  to  the  pain  caused  by  its 
injection  into  the  tissues. 

Oxycyanide  of  mercury  in  an  isotonic  solution,  or  with 
the  addition  of  its  weight  in  stovaine,  is  not  painful. 
It  is  injected  in  a  dose  of  1  centigramme. 

Neutral  salicylate  of  mercury  in  an  aqueous  2% 
solution  is  well  tolerated. 

Technique  of  Intramascular  Injections.  —  Intra- 
muscular injections  must  be  made  with  needles  of 
sufficient  length  to  reach  the  muscular  tissue,  i.e.  4  to 
5  centimetres.  I  specially  recommend  that  steel 
needles  should  be  used,  as  they  pierce  better  than 
platinum  ones,  and,  for  the  same  inside  calibre,  have 
a  smaUer  external  diameter  than  the  latter.  This  last 
point  is  of  importance  for  injection  of  grey  oil ;  it  often 
happens  that,  when  the  needle  is  withdrawn,  a  certain 
quantity  of  the  liquid  injected  runs  back  along  the 
track  ;  the  larger  the  passage  left  by  the  needle,  the 
greater  this  reflux,  and  the  more  chance  is  there  of  its 
going  into  the  cellular  tissue.  Now,  it  is  the  penetra- 
tion of  grey  oil  into  the  superficial  fascia  which  causes 
the  formation  of  subcutaneous  nodules  after  injections. 
Another  reason  has  caused  me  to  discard  platinum 
needles  :  these  are  manufactured  by  rolling  and  solder- 
ing a  platinum  plate,  and  are  often  perforated  after  a 
certain  number  of  sterilisations  in  the  flame  ;  the  result 
is  that  a  small  drop  of  grey  oil  may  escape  through  one 
of  these  perforations,  penetrate  into  the  cellular  tissue 
and  cause  the  development  of  a  nodule  there,  or  in  the 
dermis,  thus  producing  an  eschar  which  takes  a  long 
time  to  heal. 

Intramuscular  injections  of  preparations  dissolved  in 
water  can  be  made  almost  without  inconvenience  in 
the  buttock  ;  care  must  be  taken,  however,  to  avoid 
the  neighbourhood  of  the  sciatic  notch.  This  pre- 
caution is  stiU  more  necessary  with  injections  of  in- 
soluble preparations  ;   the  penetration  of  fluid  into  the 


608  SYPHILIS  AND  THE  AEMY 

vessels  which  run  through  the  sciatic  notch  might  give 
rise  to  embolism  and  cause  death. 

In  order  to  avoid  this  dangerous  zone  and,  if  nodules 
do  develop,  to  prevent  their  inconveniencing  walking 
or  dorsal  decubitus,  the  injections  should  be  made  in 
an  area  the  width  of  two  fingers  in  height  and  of  three 
fingers  in  width,  the  external  border  of  which  is  3 
centimetres  behind  the  great  trochanter  and  the  lower 
border  2  centimetres  above  the  lower  border  of  the 
trochanter  ;  or  in  the  upper  third  of  the  buttock. 

When  an  oily  fluid  is  injected,  or  insoluble  substances 
are  held  in  suspension,  I  cannot  warn  too  strongly 
that  the  injection  should  never  be  made  without  the 
needle  having  first  been  introduced  alone,  to  be  sure 
that  no  blood  appears,  the  flow  of  blood  indicating 
penetration  of  a  vesseL 

The  Intravenous  Administration  of  Mercury 

Baccelli  introduced  intravenous  injection  for  the 
administration  of  a  certain  number  of  drugs.  It  was 
employed  by  Abadie  for  the  treatment  of  ocular  sj^philis, 
and  entered  into  the  practice  of  sy philologists  long 
before  colloidal  substances  were  used  in  general  medicine. 

The  only  mercurial  salt  commonly  used  in  syphilis 
is  cyanide  of  mercury.  The  number  of  mercurial  com- 
pounds suitable  for  intravenous  injection  is  singularly 
restricted  by  the  conditions  to  be  fulfilled.  These  are 
as  follows  :  the  drug  must  be  soluble,  stable,  have  a 
fixed  and  determined  mercurial  content,  be  easily 
prepared,  sterilisable,  and,  finally,  must  not  precipitate 
the  blood  albuminoids. 

Now,  cyanide  of  mercury  practically  fulfils  all  these 
conditions.  The  radical  cyanogen  is,  as  it  were,  dis- 
simulated in  the  same  way  as  arsenic  in  organic  arsenical 
compounds  and,  from  the  point  of  view  of  toxicity,  no 
relation  can  be  established  between  it  and  cyanide  of 
potassium. 


TREATMENT  OF  SYPHILIS  609 

Aqueous  solution  of  biniodide,  which  has  been  re- 
commended by  some  authors,  has  not  been  admitted 
into  current  practice. 

The  advantages  of  intravenous  injections  are  multiple  : 
complete  absence  of  pain  when  the  injection  is  made 
correctly  ;  rapid  absorption  and  elimination  of  the 
mercury  which,  at  the  end  of  an  hour,  appears  in  the 
urine,  presenting  its  maximum  at  the  end  of  three  to 
six  hours,  hence  the  absence  of  accumulative  effects 
and  the  possibility  of  renewing  the  injections  at  short 
intervals  ;  total  absorption,  and  absence  of  all  cause 
of  error  in  dosage ;  finally,  rapid  and  energetic 
therapeutic  action.  I  shall  refer  to  this  point  again 
later. 

The  inconveniences  and  accidents  are  real,  but  may  be 
nearly  always  avoided,  given  good  technique.  They 
consist  in  the  possible  introduction  of  the  fluid  into  the 
wall  of  the  vein  and  subcutaneous  cellular  tissue,  with 
resulting  venous  indurations  and  dermo-hypodermic 
eschars ;  in  the  action  of  the  drug  on  the  digestive  tube, 
with  dysenteriform  and  hsemorrhagic  colitis.  Seeing 
the  importance  of  the  question  of  the  technique  of 
intravenous  injections  in  general  in  the  treatment  of 
syphilis,  I  have  grouped  together  in  a  special  chapter 
all  that  concerns  technique,  injection  accidents  and  the 
means  of  preventing  such  accidents  (see  p.  650). 

An  objection  raised  with  regard  to  intravenous 
injections  is  the  complicated  and  difficult  technique  : 
I  repeat  that  with  a  very  small  amount  of  skill  and 
attention  every  medical  man  should  soon  learn  how 
to  make  an  intravenous  injection  correctly.  In 
hospital,  my  pupils  succeed  at  the  end  of  a  few  days  in 
acquiring  sufficient  dexterity.  For  several  months 
many  military  surgeons  have  come  to  my  clinic  to 
learn  the  operative  technique  of  intravenous  injec- 
tions, and  have  been  able  to  perfo^-m  these  perfectly 
after  two  or  three  days  at  the  most. 

Another  objection  raised  to  intravenous  injections 


610  SYPHILIS  AND  THE  ARMY 

is  the  time  they  require  ;  it  is  certain  that,  in  a  doctor's 
practice,  an  intravenous  injection  and  its  preparation 
demand  an  appreciable  time  ;  but  this  does  not  sensibly 
exceed  that  taken  by  an  intramuscular  injection  and 
its  preparation.  In  a  hospital  treating  a  number  of 
syphilitics  and  provided  with  a  staff  of  well-trained 
dressers,  the  time  of  preparation  is  distributed  amongst 
the  total  number  of  patients  ;  it  is  reduced  in  propor- 
tion to  the  number  of  injections  made  at  the  same 
sitting,  and  what  might  be  termed  the  therapeutic 
yield  becomes  considerable. 

As  against  the  inconveniences,  one  must  put  the 
therapeutic  value  of  intravenous  injections  of  cyanide  of 
mercury.  This  value,  I  can  say  without  hesitation, 
is  enormous  and  superior  to  that  of  all  other  forms  of 
mercurialisation  ;  it  can  only  be  compared  to  that  of 
injections  of  calomel  in  tertiary  syphilitic  lesions  of  the 
mucous  membranes. 

It  is  not  rare  to  see  syphilitic  chancres  dating  from 
eight  to  ten  days  cicatrise  after  two  or  three  intra- 
venous injections  of  cyanide  of  mercury  ;  syphilitic 
lesions  of  all  sites,  secondary  or  tertiary,  mucous 
plaques  of  the  pharynx,  hypertrophic  cutaneous 
sjrphilides  become  cicatrised  or  healed  in  a  few  days. 
One  cannot  pretend  that  these  results  are  constant,  and 
I  have  seen  syphilitic  lesions  resist  this  mode  of  treat- 
ment ;  I  consider  that,  when  a  series  of  ten  to  twelve 
intravenous  injections  of  cyanide  of  mercury  has  not 
Ciffected  the  cure  of  the  syphilitic  lesion,  it  is  not  worth 
while  continuing  this  treatment  and  better  to  have 
recourse  to  another. 

It  is  none  the  less  true  that  in  the  generality  of 
cases,  especially  primary  and  secondary  lesions,  intra- 
venous injections  constitute  a  very  active  treatment, 
an  attacking  treatment  for  which  no  mercurial  prepara- 
tion, and  above  all  7io  mercurial  preparation  suited  for 
the  treatment  of  syphilis  in  soldiers,  can  be  substitvted. 
I  shall  show  later  the  practice  I  have  devised  for  the 


TREATMENT  OF   SYPHILIS  611 

purpose  of  associating  intravenous  injections  of  mercury 
and  those  of  novarsenobenzol. 

Intravenous  injections  of  cyanide  of  mercury  are 
made  with  a  1  %  solution  of  this  salt  in  sterilised  dis- 
tilled water. 

In  the  centres  where  injections  of  cyanide  of  mercury 
are  of  current  use,  this  solution  may  be  kept  in  glass- 
stoppered  bottles  ;  they  must  be  replaced  every  two 
or  three  days. 

When  there  is  only  a  small  consumption  of  cyanide, 
the  provision  must  be  kept  in  sealed  ampoules  of  1  or 
2  cubic  centimetres  capacity. 

The  injections  are  repeated  every  day,  or  every  two 
days,  according  to  the  rapidity  with  which  the  treatment 
is  to  be  carried  out.  They  may  be  given  daily  without 
inconvenience  for  twelve  to  fifteen  days  ;  but  must  be 
suspended  if  they  produce  either  stomatitis,  which  is 
rare,  colitis,  or  haemorrhagic  stools,  which  are  more 
frequent. 

The  ordinary  dose  of  cyanide  to  be  injected  at  one 
time  is  1  centigramme,  say  1  cubic  centimetre  of 
the  1  %  solution.  It  is  prudent  to  commence  with 
an  injection  of  5  milligrammes  only,  say  a  half  cubic 
centimetre,  in  debilitated  or  aged  subjects,  or  in 
those  in  whom  intestinal  troubles  are  suspected  ;  but 
if  the  first  injection  is  tolerated  well,  the  normal  dose 
of  one  centigramme  may  be  given  after  the  second  or 
third  injection. 

When  it  is  necessary  to  push  the  treatment  very 
actively,  for  example,  in  patients  whose  military 
duties  do  not  permit  more  than  a  short  sojourn  in 
hospital,  or  when  one  has  to  deal  with  grave  syphilitic 
lesions,  such  as  iritis,  meningitis,  etc.,  two  centi- 
grammes of  cyanide  {i.e.  two  cubic  centimetres)  may 
be  injected  every  day,  or  one  day  out  of  two,  in  which 
case  there  should  be  an  injection  of  one  centigramme 
on  the  intermediate  days. 

In  a  word,  the  medical  man  must  vary  the  doses 


612  SYPHILIS  AND  THE  ARMY 

according  to  the  indications  given  by  each  patient 
from  day  id  day. 

ARSENIC 

For  some  considerable  time  arsenic  has  been  used 
in  the  treatment  of  syphilis,  as  an  accessory  medica- 
tion. Donovan's  solution,  which  dates  from  1839, 
contains  it  in  association  with  iodide  of  potassium  and 
mercury  ;  numerous  medical  men  add  arsenic,  either 
to  mercury  or  iodide  of  potassium,  and  use  it  for 
combating  the  anaemia  and  asthenia  of  syphilitics,  or 
prescribe  thermal  baths  for  these  patients,  where  the 
waters  contain  arsenic,  especially  at  Bourboule. 

From  the  time  that  Armand  Gautier  introduced 
arsenical  derivatives  with  an  organic  base  into  thera- 
peutics, these  have  been  employed  largely  in  anti- 
syphilitic  therapy.  Brocq  obtained  good  results  with 
iodo-mercuric  cacodylate ;  arrhenate  of  mercury, 
salicylar senate  of  mercury  have  been  used.  Anilar- 
sinate  of  sodium,  which  was  discovered  by  Bechamp  in 
1863,  reappeared  in  Germany  in  1907,  under  the  name 
of  atoxyl,  and  enjoyed  an  ephemeral  vogue,  but  was 
soon  abandoned  owing  to  the  numerous  and  serious 
accidents  it  caused  (blindness,  death). 

In  1909,  Balzer  obtained  good  results  with  henzo-sul- 
phono-para-amidophenylarsinate  of  sodium,  discovererd 
by  Mouneyrat  and  sold  under  the  name  of  hectine ; 
associated  with  mercury  in  a  special  preparation, 
under  the  name  of  hectargyre,  it  had  a  certain  vogue, 
which  rapidly  diminished  upon  the  appearance  of 
arsenobenzol. 

Aisenobenzol 

Dichlorhydrate  of  dioxydiamido-arsenohenzol  was  dis- 
covered by  Ehrlich,  in  1909,  when  experimenting  with 
arsenical  compounds  on  the  spirilloses.     It  is  commonly 


TREATMENT   OF   SYPHILIS  613 

known  by  the  name  of  "  606,"  which  indicates  its 
number  in  the  series  of  Ehrlich's  experiments.  It 
has  been  patented  under  the  name  of  Salvarsan  by  the 
Hoechst  Chemical  Manufacturing  Dye-works  of  Meister 
Lucius,  and  Briining.  The  name  arsenohenzol,  a 
simplification  of  its  chemical  denomination,  under 
which  it  has  been  manufactured  and  sold  everywhere, 
should  be  the  only  ond  used. 

Arsenohenzol  is  a  canary  yellow  powder,  impalpable 
to  the  touch,  of  an  astringent  and  acid  taste,  with  a 
slightly  sulphurous  odour  ;  it  changes  under  contact 
with  the  air,  and  must  be  kept  in  hermetically  sealed 
phials,  in  nitrogen. 

In  water,  it  gives  a  solution,  with  an  acid  reaction. 

It  was  at  first  used  for  intramuscular  injections,  in 
the  form  of  an  acid  oily  suspension,  but  this  method 
of  employment  was  soon  abandoned  owing  to  the 
severe  pain  it  caused.  Arsenohenzol  was  then  adminis- 
tered solely  by  intravenous  injection  :  its  aqueous 
solution,  being  acid,  has  been  abandoned,  on  account 
of  the  painful  reactions  it  caused  ;  recourse  has  been 
had  to  neutralised  solutions,  or  those  rendered  alkaline 
by  the  addition  of  solution  of  soda. 

The  quantity  of  solution  of  soda  to  be  added  varies 
in  accordance  with  the  doses  injected. 

The  addition  of  solution  of  soda  to  the  aqueous 
solution  of  arsenohenzol  produces  a  precipitate,  which 
dissolves  on  the  addition  of  more  alkaline  solution. 

Arsenohenzol  solution,  rendered  alkaline  by  soda, 
cannot  be  injected  unless  diluted  by  a  certain  quantity 
of  physiological  serum,  so  that  the  volume  injected 
shall  reach  150  to  200  cubic  centimetres. 

Each  operator  prefers  his  special  method,  the  pre- 
paration of  the  solution,  and  the  instruments  necessary 
for  the  injection  having  been  subjected  to  numerous 
modifications.  It  is  not  possible  here  to  give  details 
of  these  different  techniques,  the  more  so  because,  as 
I  shall  state  later  on,  I  do  not  consider  arsenobenzol 


614  SYPHILIS   AND   THE  ARMY 

can  be  utilised  in  the  treatment  of  syphilis  in  the 
Army. 

When  first  used,  arsenobenzol  gave  rise  to  the 
greatest  hopes,  Ehrlich  did  not  hesitate  to  say  that 
it  enables  one  to  efifect,  by  means  of  a  few  injections, 
the  "  sterilisatio  magna  "  of  syphilis.  Experience 
quickly  showed  that,  even  granting  that  these  injec- 
tions given  at  the  onset  of  syphilis  were  indeed  followed 
in  a  short  time  by  cicatrisation  of  the  chancre,  if  the 
secondary  symptoms  did  not  appear  at  their  ordinary 
date,  they  were  simply  delayed  and  were  frequently 
seen  later.  In  an  attempt  to  stop  the  secondary 
symptoms,  it  was  necessary  to  increase  the  number  of 
injections.  True,  when  the  disease  was  more  advanced, 
active  troubles  certainly  disappeared,  most  frequently 
in  a  marvellous  way,  but  these  also  reappeared  at  the 
end  of  some  weeks,  and  sometimes  then  resisted 
arsenobenzol,  even  in  large  doses  frequently  repeated. 
Thus  the  initial  enthusiasm  was  damped  ;  injections 
were  multiplied,  and  doses  increased. 

Moreover,  accidents  happened,  even  deaths  being 
reported.  Many  of  these  accidents  were  due  to  errors 
of  technique  or  the  use  of  excessive  doses  and  could 
not  be  attributed  to  the  drug.  As  regards  the  deaths, 
the  majority  were  due  to  the  general  condition  of  the 
patients.  Ehrlich  soon  announced  that  there  were 
contra-indications  to  the  use  of  arsenobenzol,  and 
advised  its  non-employment  in  cardiac  affections, 
aortic  aneurisms,  and  general  paralysis. 

Nevertheless,  disastrous  results  were  stUl  observed 
sometimes  ;  it  had  to  be  acknowledged  that,  granting 
they  were  more  frequent  in  old  age,  and  in  cardiac, 
albuminuric,  hepatic,  and  cachectic  patients,  they  were 
also  observed  in  young,  apparently  healthy  subjects. 
It  was  soon  noticed  that  they  rarely  appeared  with 
the  first  injection,  but  most  often  with  the  second, 
diminishing  in  frequency  with  the  third  and  subsequent 
ones. 


TREATMENT  OF   SYPHILIS  615 

Further,  nervous  troubles  such  as  paralysis  of  the 
cranial  nerves  sometimes  appeared  in  patients  treated 
by  arsenobenzol  ;  their  frequency  aroused  distrust  of 
the  drug 

I  shall  revert  again  later  to  the  question  of  accidents. 

Arsenobenzol  caused  accidents,  independent  of  the 
doses  of  the  drug  injected,  as  well  as  of  the  technique  ; 
it  necessitated  a  complicated  technique,  and,  despite 
improvements,  few  medical  men  were  persuaded  to 
use  it. 

The  discovery  by  Ehrlich  of  a  substance,  of  closely 
allied  chemical  composition,  easily  giving  a  perfect 
solution  with  neutral  reaction,  rendered  the  arsenical 
medication  of  syphilis  practicable. 

Novarsenobenzol 

Dioxydiamido  arsenobenzolmonomethylene  sulphoxy- 
late  of  sodium  was  called  "  914  "  by  Ehrlich,  in  accord- 
ance with  its  position  in  his  experiments  ;  it  was  sold 
by  the  firm  of  Meister,  Lucius,  and  Briining,  under  the 
name  of  Neosalvarsan.  By  way  of  analogy  with 
arsenobenzol,  it  is  generally  designated  under  the  name 
of  Novarsenobenzol.  Like  arsenobenzol,  it  can  be 
prepared  and  sold  by  all  manufacturers  of  chemical 
products. 

It  is  a  bright  yellow  *  powder,  of  impalpable  con- 
sistency ;  when  placed  on  water  it  floats,  but  melts 
with  extreme  rapidity,  making  a  clear  solution,  of 
neutral  reaction,  which  can  be  injected  into  the  veins 
direct. 

The  perfect  and  rapid  solubility  of  novarsenobenzol 
in  water  in  every  proportion,  or  in  physiological  serum, 

*  When  novarsenobenzol  changes,  its  colour  becomes  brown. 
Before  making  the  solution,  care  should  always  be  taken  to  see 
that  the  product  has  retained  its  normal  colour.  It  is  well  to  know 
that  the  density  of  novarsenobenzol  is  not  always  constant,  so  that 
the  volume  in  the  ampulla  occupied  by  the  same  dose  of  the  drug 
may  vary  considerably. 


616  SYPHILIS  AND   THE  ARMY 

has  caused  this  substance  to  obtain  a  well-merited 
renown. 

Novarsenobenzol  changes  rapidly  when  in  contact 
with  the  air  :  like  arsenobenzol,  it  must  also  be  pre- 
served in  hermetically  sealed  ampoules.  This  is  the 
form  in  which  it  is  put  on  the  market  and  delivered 
to  medical  centres,  by  the  Central  Pharmacy  of  Military 
Hospitals  and  the  local  pharmacies,  in  ampoules  con- 
taining doses  of  0*15  gr.,  0*30  gr.,  0'45  gr.,  0"60  gr., 
0"75  gr.,  090  gr.,  the  doses  usually  employed  for 
the  treatment  of  syphilis.  The  ampoules  have  a 
uniform  capacity  of  4  to  5  cubic  centimetres. 

The  activity  of  novarsenobenzol  is  lower  than  that 
of  arsenobenzol  ;  both  from  the  point  of  view  of 
toxicity  and  of  therapeutic  effects,  it  may  be  regarded 
as  equal  to  two-thirds  of  that  of  arsenobenzol.  Thus, 
the  doses  should  be  half  as  much  again  as  those  of  the 
latter  drug. 

Novarsenobenzol  solution  should  be  prepared  the 
moment  it  is  to  be  used  ;  its  effect  changes  on  contact 
with  the  air,  and  this  becomes  more  accelerated  the 
higher  the  temperature.  Further,  these  solutions 
should  be  used  with  cold  ivater. 

The  Vehicle  for  Injections  of  Novarsenobenzol 

Amongst  the  causes  of  accidents  due  to  the  use  of 
arsenobenzol,  great  importance  has  been  attributed 
to  the  liquids  used  in  preparing  the  solutions  ;  the 
question  of  the  water  has  been  the  subject  of  numerous 
investigations,  and,  in  the  production  of  toxic  accidents, 
all  impurities  of  the  water,  both  chemical  and  microbial, 
have  been  incriminated  ;  salts  of  lead,  alkaline  silicates, 
bicarbonate  of  lime  or  magnesia,  derived  from  the 
glass  of  the  distilling  apparatus,  copper  if  this  was  in 
metal.  Chloride  of  sodium  was  also  blamed  if  the 
injection  was  made  with  physiological  serum.  It  was 
not  sufficient  for  the  water  to  be  distilled,   it  was 


TREATMENT  OF  SYPHILIS  617 

necessary  that  it  should  be  distilled  at  least  twice, 
the  last  time  being  on  the  day  itself,  or  the  evening 
preceding,  its  use  ;  further,  it  was  imperative  that  it 
should  be  distilled  in  an  apparatus  made  of  special 
glass. 

When  novarsenobenzol  was  first  used  it  was  dissolved 
in  150  to  200  cubic  centimetres  of  fluid,  like  arseno- 
benzol. 

Ravaut  *  made  a  great  advance  in  the  technique  of 
treatment  by  novarsenobenzol  when  he  showed  that 
the  question  of  water  could  be  solved  in  a  very  simple 
fashion,  by  reducing  the  quantity  of  the  vehicle  ;  by 
injecting  less  liquid,  and  thus  injecting  a  smaller 
quantity  of  toxic  substances  contained  in  it. 

But  when  a  liquid  is  injected  into  the  veins  it  must 
not  alter  the  blood  corpuscles  and  cause  haemolysis. 

Traditionally,  to  avoid  haemolysis,  it  was  customary 
to  dissolve  the  novarsenobenzol  in  physiological  serum. 
Ravaut  showed  that  solutions  of  novarsenobenzol 
respect  the  integrity  of  the  blood  corpuscles  provided 
a  certain  content  of  arsenobenzol  is  maintained  :  this 
content,  in  his  opinion,  is  0  45  gr.  for  10  cubic  centi- 
metres of  distilled  water.  Therefore  for  the  injection 
of  a  full  dose  of  novarsenobenzol,  0'45  gr.  or  more,  only 
10  cubic  centimetres  of  distilled  water  need  be  used, 
with  a  proportionate  volume  for  smaller  doses,  say 
3  cubic  centimetres  for  0*15  gr.  of  novarsenobenzol. 

Later,  Ravaut  f  showed  that  the  quantity  of  liquid 
injected  could  be  still  further  diminished.  The  solu- 
bility of  novarsenobenzol  in  water  is  such  that  two 
cubic  centimetres  of  water  will  dissolve  0'90  gr.     These 

*  Ravaut,  "  New  Process  of  Intravenous  Injection  of  Neosal- 
varsan"  {Bulletin  de  la  Societe  francaise  de  Dermatologie,  Feb- 
ruary 7th,  1913,  p.  118).  Ravaut  and  Scheikeviteh,  "Study  on 
the  New  Process  of  Injection  of  Neosalvarsan  in  Concentrated  Solu- 
tions"  {Annates  de  Dermatologie,  April  1913,  p.  208). 

t  Ravaut,  "  New  Simplification  of  the  Technique  of  Concentrated 
Intravenous  Injections  of  Arsenobenzol"  {Presse  medicale,  October 
1915,  p.  398). 


618  SYPHILIS  AND   THE  ARMY 

concentrated  solutions  do  not  alter  the  blood  ;  they 
cause  no  inconvenience,  except  that  they  may  be  pain- 
ful if,  by  accident,  the  fluid  is  injected  outside  the 
vein  (see  "The  Technique  of  Intravenous  Injections," 
p.  650).  It  is  wise,  however,  to  make  the  injection 
more  slowly  than  with  larger  quantities  of  solutions. 

The  water  problem  is  solved  by  the  method  of 
concentrated  injections,  and  to  such  a  point  that  it  is 
no  longer  even  necessary  to  use  distilled  water  for  these 
injections.  In  a  hospital  at  the  front,  Ravaut  has 
performed  injections  with  water  that  had  been  simply 
boiled  and  filtered  through  absorbent  wool,  without 
causing  any  accident. 

I  have  myself  proved  on  several  occasions  that 
injections  of  novarsenobenzol,  dissolved  in  ordinary 
water,  which  had  been  sterilised  by  boiling  for  some 
minutes,  do  not  cause  accidents  of  any  kind,  and  no 
greater  febrile  reaction  than  those  made  with  freshly 
distilled  water. 

Nevertheless,  one  must  not  use  water  too  highly 
charged  with  calcareous  salts,  as  they  would  react  on 
the  novarsenobenzol.  When  it  is  impossible  to  obtain 
any  other,  calcareous  water  may  be  used,  if  it  is  boiled 
a  long  time,  in  order  to  precipitate  the  calcareous  salts, 
and  then  sterilised  afresh  by  boiling  after  decanting. 

To  summarise,  injections  of  novarsenobenzol  may 
be  made  with  physiological  serum,  distilled  water  which 
has  been  prepared  less  than  three  months,  preserved 
aseptically  or  recently  boiled,  and  in  case  of  urgency 
with  ordinary  water  boiled  and  filtered  through  cotton- 
wool, in  a  volume  of  two  cubic  centimetres  per  injection, 
whatever  the  dose  of  novarsenobenzol. 

This  method  of  highly  concentrated  injections  is 
recommended  on  account  of  its  simplicity,  and  the 
facility  with  which  the  necessary  material  and  appro- 
priate syringes  can  be  obtained.  It  is  also  recom- 
mended because  of  its  innocuousness,  by  reducing  the 
accidents  due  to  the  drug  to  a  minimum.      It  is  the 


TREATMENT  OF   SYPHILIS  619 

only  method  I  have  used  in  my  hospital  work  for  the 
past  year  ;  it  responds  better  than  any  other  to  the 
requirements  of  antisyphilitic  therapy  in  the  Army  and 
at  the  medical  centres. 

Balzer  and  Dumouthiers  have  recommended  intra- 
muscular injections  of  novarsenobenzol.  This  method, 
which  may  be  compared  to  injections  of  insoluble 
mercurial  preparations,  has  the  advantage  of  not 
introducing  a  high  dose  of  arsenic  into  the  circulation  ; 
it  is  therefore  less  dangerous  than  the  method  of  intra- 
venous injections. 

Injections,  in  doses  of  025  gr.,  are  made  twice  a 
week. 

As  a  rule,  they  are  painless,  but  sometimes  painful. 

But,  as  with  intramuscular  mercurial  injections,  the 
possibility  of  painful  local  reaction  prohibits  the 
adoption  of  this  method  for  the  army.  Moreover,  its 
therapeutic  action  appears  to  be  both  less  intense  and 
less  rapid  than  that  of  intravenous  injections. 

The  Effects  of  Novarsenobenzol  on  Syphilitic  Manifestations 

Like  arsenobenzol,  but  in  higher  doses,  novarseno- 
benzol has  a  very  rapid  action  on  the  cicatrisation  of 
syphilitic  chancre,  even  in  its  early  stages,  and  no 
matter  what  its  extent.  From  the  very  first  days,  the 
chancre  becomes  of  a  paler  colour,  its  borders  are  less 
marked,  the  basal  induration  diminishes,  its  appear- 
ance resembles  that  of  simple  ulceration,  its  surface 
contracts,  and,  within  the  space  of  6  to  12  days,  it 
has  completely  cicatricised ;  the  satellite  glands,  once 
treatment  has  begun,  cease  to  increase  in  size,  become 
less  hard,  and  within  a  few  days  again  resume  their 
normal  dimensions. 

The  effects  are  no  less  remarkable  on  secondary 
lesions.  The  mucous  plaques  of  the  genital  organs, 
anus  and  mouth  are  very  rapidly  influenced  by  the 
drug.     If  they  are  of   the  erosive  form  they  heal   in 


620  SYPHILIS  AND  THE  ARMY 

4  to  6  days  ;  hypertrophic  plaques,  even  the  most 
voluminous,  subside  from  the  first  2  or  3  days  follow- 
ing the  first  injection,  lose  their  papillomatous  appear- 
ance, and  in  12  to  15  days,  i.e.  after  the  second  injection, 
they  have  completely  disappeared,  without  any  local 
treatment. 

Cutaneous  lesions  are  also  influenced  rapidly  by 
novarsenobenzol ;  as  with  all  active  treatment,  mer- 
curial, as  well  as  arsenical,  they  are  often  the  seat  of 
a  more  or  less  local  congestion,  known  under  the  name 
of  Herxheimer's  Reaction,  during  the  first  hours 
following  the  injection.  After  this  temporary  con- 
gestion, they  fade  rapidly  and  disappear  ;  roseola  in 

5  to  8  days,  papular  syphilides  with  large  papules  in 
the  space  of  6  to  8  days,  syphilitic  plaques  of  the  skin 
a  little  more  rapidly  ;  papular  syphilides  with  small 
papules  resist  treatment  more  and  do  not  always 
disappear  after  the  third  or  even  the  fourth  injection  ; 
ulcerous  syphilides  heal  fairly  rapidly,  and  their  cica- 
trisation may  be  complete  in  8  to  15  days,  even  if 
they  are  extensive  and  deep. 

The  rapid  influence  of  arsenobenzol  on  cutaneous 
lesions  of  syphilis,  especially  on  ulcerous  syphilides, 
has  led  some  authors  to  state  that  the  principal  effect 
of  this  drug  is  to  hasten  cicatrisation,  and  some  have 
denied  that  it  had  any  other  quality. 

It  is  incontestable,  however,  that  it  has  an  action 
on  the  visceral  manifestations  of  syphilis,  which  is  as 
rapid  as  that  which  it  exercises  on  the  cutaneous 
lesions. 

Secondary  syphilitic  headache  is  nearly  always 
influenced  by  it.  It  is  not  unusual  for  patients  suffer- 
ing from  violent  headache  and  consequent  insomnia 
for  several  days  to  regain  sleep  the  night  or  following 
night,  after  the  first  injection.  The  same  thing  applies 
to  the  pains  in  the  limbs,  which  are  sometimes  so 
distressing  in  secondary  syphilis. 

More  serious  troubles,  such  as  hemiplegia  of  the 


TREATMENT   OF   SYPHILIS  621 

face  and  limbs  and  medullary  lesions  of  secondary 
syphilis,  are  also  influenced  rapidly. 

Iritis  and  Irido-ckoroiditis  are  very  quickly  modified 
by  novarsenobenzol  ;  the  preorbital  pain  yields  in  a 
few  days,  sometimes  in  a  few  hours,  the  iris  regaining- 
its  contractility  and  coloration  ;  no  more  adhesions 
are  produced,  and  in  fifteen  to  twenty  days  the  iris 
has  resumed  its  normal  aspect,  with  the  exception  of 
a  slight  sluggishness  and  some  tendency  to  dilatation, 
and,  of  course,  the  cicatrised  remains  of  adhesions 
prior  to  treatment. 

The  general  condition  of  the  patient  responds  very 
rapidly  to  the  influence  of  arsenical  medication  ;  the 
febrile  condition  common  in  secondary  syphilis  subsides 
in  two  or  three  days,  the  sensation  of  fatigue  so  frequent 
in  the  early  stages,  the  pallor  or  earthy  colour  of  the 
face,  rapidly  give  place  to  a  sensation  of  well-being, 
normal  coloration  of  the  skin,  and  renewed  vigour. 
Many  syphilitics  declare  that  their  health  is  far  better 
since  treatment  with  arsenobenzol  than  it  was  before 
the  onset  of  syphilis  :  they  soon  put  on  flesh  to  a 
noticeable  extent,  their  appetite  returns,  and  often 
the  growth  of  hair  is  more  abundant  than  it  was  before. 
The  above  are  the  effects  of  any  active  arsenical 
medication,  at  the  maximum  of  intensity  and  rapidity, 
owing  to  the  richness  of  the  drug  in  arsenic. 

With  patients  who  had  previously  been  subjected 
to  mercurial  medication  and  in  whom  this  drug  had 
reacted  on  the  buccal  mucous  membrane,  a  very  rapid 
modification  of  the  mercurial  gingivitis  must  be  added 
to  these  favourable  effects  :  the  ulceratioiis  become 
clean  and  heal,  salivation  ceases  and  mercurial  treat- 
ment can  be  renewed  later  on  without  bringing  about 
a  return  of  the  stomatitis. 

To  sum  up,  in  the  great  majority  of  cases,  excepting 
the  rare  instances  of  intolerance  or  resistance  to  the 
drug,  novarsenobenzol,  like  arsenobenzol,  rapidly  causes 
the  disappearance  of  the  lesions  of  primary  and  secon- 


622  SYPHILIS   AND   THE  ARMY 

dary  syphilis,  and  at  the  same  time  improves  the 
general  condition  of  the  patient  to  a  degree  not  attained 
by  mercury. 

This  is  undoubted,  and  evidence  would  have  to  be 
repudiated  if  it  were  not  acknowledged. 

The  question  is,  whether  the  action  of  arsenobenzol 
is  symptomatic — a  rapid  and  energetic  action  on  the 
lesions  only,  or  fundamental — a  curative  action  on  the 
disease  itself.  In  a  word,  does  novarsenobenzol 
"  whitewash  "  the  syphilitics,  or  does  it  cure  syphilis  ? 
I  have  already  said  that  the  sterilisatio  magna  an- 
nounced by  Ehrlich  has  not  been  realised  by  a  small 
number  of  injections  of  arsenobenzol.  Can  this  result 
be  obtained  by  multiplying  the  injections,  and  using 
higher  doses  of  the  drug  ? 

Opinions  vary.  Some  hold  that  sufficiently  energetic 
treatment  will  cure  syphilis  radically  and  definitely. 
According  to  others,  this  result  is  never  attained. 

One  fact  seems  now  to  be  established,  i.e.  that,  in 
order  to  hope  to  sterilise  syphilis  by  arsenobenzol  or  by 
novarsenobenzol,  the  disease  must  be  attacked  from 
the  primary  period,  preferably  from  the  second  or 
third  weeks  of  the  chancre,  and  that,  once  the  secondary 
troubles  have  appeared,  one  can  no  longer  expect  such 
a  result. 

In  what  proportions  has  this  sterilisation  been 
realised  in  cases  of  syphilis  treated  from  the  onset  ? 
This  is  difficult  to  ascertain.  Some  authors  claim 
results  which  are  truly  marvellous.  But  their  statistics 
are  generally  based  on  the  experience  of  a  few  months, 
and  their  statement  that  sypl^ilis  has  been  sterilised 
rests  on  the  fact  that  no  symptoms  have  been  seen 
during  the  period  of  observation,  and  that  the  Wasser- 
mann  rection  became  and  remained  negative. 

This  last  argument  is  inadequate,  no  matter  what 
has  been  said,  to  justify  one  in  asserting  that  the 
syphilis  has  been  cured.  Prolonged  observation  during 
several  years  would  alone  authorise  this  conclusion. 


TREATMENT  OF   SYPHILIS  623 

In  fact,  syphilis,  treated  either  by  mercury  or  not  at 
all,  may  remain  for  many  years  without  any  external 
signs,  and  yet  manifest  more  or  less  serious  symptoms 
at  the  end  of  12,  15  years  and  more — I  have  even  seen 
a  case  after  54  years. 

An  apparently  more  weighty  argument  has  been 
supplied  by  the  fairly  numerous  observations  of  several 
medical  men,  who,  after  treating  a  syphilitic  chancre 
by  arsenobenzol,  have  seen  a  new  one  develop  later. 
In  virtue  of  the  axiom  that  an  infective  disease  which 
recurs  is  one  in  which  the  first  attack  has  been  cured, 
one  must  conclude  that  the  first  attack  of  syphilis  had 
been  cured. 

I  have  already  shown,  with  regard  to  the  diagnosis 
of  syphilitic  chancre  (see  page  5B6)  the  probable  ex- 
planation of  some  lesions — the  majority,  in  my  opinion 
— regarded  as  reinfection  chancres  in  patients  treated 
by  arsenobenzol. 

Apart  from  the  pseudo-chancre  of  reinfection,  later 
syphilitic  manifestations  are  often  seen  in  patients 
treated  by  arsenobenzol. 

After  a  latent  period  of  several  months,  lesions 
of  the  mucous  membranes,  simple  or  hypertrophic 
plaques,  may  appear,  often  accompanied  by  a  circinate 
erythematous  eruption,  of  the  type  of  recurrent  roseola 
(see  p. 5/4)  which  respond  again  to  treatment  with 
arsenobenzol  or  mercury,  sometimes  to  again  reappear 
after  ^  variable  period. 

Other  syphilitic  manifestations  of  different  kinds 
and  varied  locations  may  also  appear,  especially 
nervous  affections,  and  these  I  shall  mention  again. 

What  is  remarkable  is  that  the  most  characteristic 
symptoms  of  the  secondary  period  are  usually  absent ; 
the  typical  roseola  is  not  observed  in  patients  treated 
with  arsenobenzol.  Again,  delayed  lesions  of  the 
tertiary  type  often  occur  at  a  period  at  which  they 
would  not  have  had  time  to  appear  in  untreated  syphilis 
or  that   treated  by   mercury.     Arsenical   medication 


621  SYPHILIS   AND   THE   ABMY 

seems  both  to  retard  or  inhibit  the  appearance  of 
early  les'  ns  and  hasten  the  appearance  of  the  later 
manifestations  of  syphilis. 

Detractors  of  arsenical  medication  have  taken 
advantage  of  the  appearance  of  these  delayed  lesions, 
and  have  cited  cases  in  which  they  appeared  after 
arsenical  treatment  of  varying  intensity  and  duration. 

It  is  impossible  to  deny  that  patients  treated  by 
high  and  repeated  doses  of  arsenobenzol,  from  the 
first  days  of  the  chancre,  have  presented  indubitable 
syphilitic  lesions,  of  a  more  or  less  serious  character, 
at  the  end  of  a  few  months. 

On  the  other  hand,  trustworthy  observers  have  cited 
cases  treated  from  the  first  days  of  chancre  with 
arsenobenzol,  in  which  the  Wassermann  Reaction  has 
become  negative  and  remained  so  for  two  or  three 
years,  without  the  appearance  of  any  syphilitic  trouble. 

It  is,  therefore,  justifiable  to  conclude  that  arseno- 
benzol may  definitely  cure  syphilis,  when  it  is  employed 
at  the  initial  period,*  but  also  that  definite  cures 
obtained  with  this  drug  are  rare,  no  matter  at  what 
period  of  syphilis  it  is  instituted  or  what  dose  is  given. 

With  regard  to  the  Army,  this  conclusion  should 
lead  medical  men  to  regulate  the  use  of  arsenical 
medication  in  the  hope  of  attenuating  syphilis,  and 
curing  it  if  possible.  It  does  not  justify  them,  how- 
ever, in  endeavouring  to  obtain  a  result  which  is 
always  exceptional,  by  means  of  extremely  energetic 
and  prolonged  medication  which  would  prevent  the 
patient  from  performing  his  military  duties  and 
diminish  the  number  of  efficient  soldiers. 

This  consideration  is  of  importance,  owing  to  the 
fact  that  it  is  not  certain  whether  very  high  doses 
and  prolonged  use  of  arsenobenzol  may  not  have  a 
noxious  effect.     During  the  six  years  in  which  arseno- 

*  See  specially  Brocq's  memoire  ("  How  to  administer  Salvarsan," 
Annales  de  dermatologie ,  December  1912,  p.  669)  in  which  this 
question  is  handled  with  the  greatest  caution. 


TREATMENT  OF   SYPHILIS  625 

benzol  has  been  used,  we  cannot  pretend  to  be 
acquainted  yet  with  its  remote  effects.  When  the 
nervous  system  frequently  responds  to  arsenobenzol 
by  a  reaction  which  ends  in  grave  disorders,  it  is 
possible  that  too  energetic  initial  treatment  may  lead 
to  more  or  less  pronounced  inflammatory  conditions, 
and  perhaps  predispose  to  terminal  localisations  of 
the  treponema  in  the  grey  matter. 

There  is  a  risk,  of  which  the  civil  surgeon  should 
warn  his  patient,  when  proposing  an  energetic  abortive 
treatment,  but  which  the  army  surgeon  doe^  not 
appear  to  have  the  right  of  imposing  upon  the  men 
who  are  confided  to>  his  care. 

In  what  Doses  should  Novarsenobenzol  be  injected? 

The  most  varied  and  contradictory  opinions  have 
been  stated  as  to  the  suitable  doses  of  the  arsenical 
compound  to  be  injected. 

Ehrlich,  relying  on  his  experimental  researches,  fixed 
the  dose  of  arsenobenzol  at  one  centigramme  per 
kilogramme  of  body  weight,  and  stated  that  this 
should  never  be  exceeded  at  one  injection.  Assuming 
that  the  toxicity  of  novarsenobenzol  is  two-thirds  that 
of  arsenobenzol,  the  maximum  dose  for  a  man  of  aver- 
age weight  of  the  new  compound  is  1  '5  centigramme  per 
kilogramme. 

The  great  majority  of  authors  agree  that  it  is  never 
necessary  to  give  this  dose,  and  no  one  advises  it  for 
the  first  injection. 

All  agree  that  the  first  injections — or  at  least  the 
first  one — should  be  made  with  smaller  doses  than  the 
succeeding  ones.  By  a  massive  dose  at  the  beginning, 
too  great  a  number  of  the  treponemas  are  destroyed 
at  one  stroke,  and  the  products  of  bacteriolysis  add 
their  noxious  action  to  those  of  the  drug,  and  cause 
intense  reactions.  Further,  as  experience  has  proved, 
the  organism  has  to  become  accustomed  to  the  toxicity 


626  SYPHILIS  AND   THE   ARMY 

of  the  arsenic,  so  that  a  dose,  which  at  the  first  injection 
would  cause  toxic  troubles,  does  not  do  so  if  the  ground 
has  already  been  prepared  by  previous  injections. 
This  tolerance  disappears,  or  is  at  least  attenuated 
by  time,  so  that  if  medication  by  arsenobenzol  or 
novarsenobenzol  is  resumed  after  a  period  of  rest, 
the  first  injection  must  be  made  with  a  smaller  dose 
than  the  last  of  the  preceding  series. 

Finally,  it  seems  evident  that  the  susceptibility  of 
all  patients  to  the  toxicity  of  arsenobenzol  is  not  the 
same  ;  the  first  injection  enables  one  to  feel  one's 
way,  and  reduce  the  dose  of  this  drug  in  subjects 
who  are  intolerant. 

For  all  these  reasons,  it  is  rational,  and  experience 
has  shown  it  necessary,  not  to  give  the  highest  dose  of 
the  drug  at  the  beginning  of  treatment. 

But  with  what  dose  should  one  commence  ?  Some 
authors,  alarmed  by  the  accidents  observed,  have 
proposed  that  one  should  start  with  very  small  doses, 
0*30  gr.,  or  even  01 5  gr.  of  novarsenobenzol,  and  in- 
crease this  progressively  by  015  gr.  at  each  injection. 

Others,  not  less  expert  in  therapeutic  matters, 
commence  with  0*60  gr.  of  novarsenobenzol,  reach 
0'75  gr.  at  the  second  injection,  and  often  keep  to  this 
dose  for  the  following  ones  ;  they  do  not  seem  to  have 
had  more  accidents  with  this  method  than  others  who 
are  more  cautious. 

Every  one  has  been  guided  in  his  line  of  conduct  by 
the  facts  observed  and  the  theories  he  has  evolved. 

As  far  as  I  myself  am  concerned,  I  was  struck  by 
two  fatal  cases  in  young  women  after  small  doses 
of  novarsenobenzol.  In  one  case,  the  first  injection 
had  been  made  with  a  dose  of  020  gr.,  the  second  of 
0  15  gr.  ;  in  the  other  case,  the  injections  were  respec- 
tively 0  30  gr.  and  0'45  gr.  As  I  constantly  use  larger 
doses  without  accident,  I  do  not  consider  that  weak 
initial  doses  are  free  from  risk,  and  think  there  is  no 
danger  in  commencing  with  a  dose  of  0  45  gr.  in  healthy 


TREATMENT  OF  SYPHILIS  627 

men.  In  women  I  generally  reduce  the  initial  dose 
to  0'30  gr.,  and  even  in  men  who  are  anaemic,  or 
nervous  subjects  upset  by  the  idea  of  the  danger  of 
arsenobenzol,  or  presenting  some  taint  or  suspected 
history  (albuminuria,  cardiac  disturbance,  etc.). 

With  young  and  healthy  subjects,  like  most  men 
serving  in  the  Army,  the  initial  dose  of  0'45  gr.  never 
shows  any  contra-indication.  By  beginning  with  an 
active  dose,  one  has  the  advantage  of  reducing  the 
duration  of  treatment  and  hospitalisation,  an  advant- 
age which,  in  time  of  war,  must  always  be  aimed  at, 
if  it  is  not  purchased  too  dearly. 

When  the  first  injection  has  been  badly  borne  and 
has  caused  a  febrile  reaction,  arsenic  intolerance  must 
be  suspected.  It  is,  therefore,  prudent  to  suspend 
the  use  of  the  drug,  at  any  rate  for  a  time,  and,  if 
imperative  to  again  resort  to  it,  the  weakest  doses 
must  be  given,  01 5  gr.  for  example,  and  its  effects 
carefully  watched. 

In  the  following  injections,  the  dose  should  be  in- 
creased to  0'60  gr.  and  0'75  gr.  In  the  majority  of 
cases,  contagious  lesions  are  cicatrised  after  the  second 
injection,  given  in  a  dose  of  0'60  gr.,  and  if  necessary 
we  can  limit  ourselves  to  these,  on  condition,  as  I 
shall  show  later  on,  that  mercurial  treatment  is  con- 
tinued. Many  of  my  patients,  who  were  given  two 
injections  only,  before  being  subjected  to  mercurial 
treatment,  did  not  later  present  any  syphilitic 
symptoms. 

Nevertheless,  I  consider  that  it  is  more  efficacious 
to  begin  with  a  dose  of  0  45  gr.,  which  is  fairly  high  ; 
the  therapeutic  effect  of  two  successive  doses  of  0'45  gr. 
and  0'60  gr.  is  at  least  equal  to  that  of  these  two  doses 
preceded  by  one  injection  of  015  gr.  or  of  0'30  gr. 

If  the  cure  of  the  contagious  troubles  is  delayed,  a 
fresh  injection  will  generally  have  the  desired  effect. 

Some  authors  consider  that  a  cure  is  more  certain 
and  durable,  and  the  chances  of  the  return  of  syphilitic 


628  SYPHILIS  AND   THE  ARMY 

symptoms  more  remote,  if  the  treatment  is  continued. 
They  also  advise  that  the  injections  should  be  continued 
until  a  total  dose  of  about  3  grammes  has  been  reached, 
which  represents  an  injection  of  0'45  gr.  and  four 
injections  of  0'60  gr.  or  one  injection  of  0'45  gr.,  one 
of  0'60  gr.,  one  of  075  gr.,  and  one  of  0'90  gr. 

The  utility  of  such  doses  is  not  evident  to  me  ;  I  do 
not  think  that  they  have  an  absolutely  prophylactic 
action  against  later  troubles,  and  I  consider  that  this 
action  is  obtained  more  certainly  by  the  association 
of  mercury. 

Periodicity  of  the  Injections 

It  is  necessary  to  have  intervals  between  the  in- 
jections, in  order  to  permit  the  organism  to  eliminate 
the  drug,  which  requires  four  to  five  days,  and  to  recover 
from  the  shock  induced,  and  the  humoral  and  visceral 
troubles  that  have  been  provoked.  It  is  admitted 
almost  unanimously  that  the  interval  between  two 
injections  should  be  a  week.  Even  if  small  doses  of 
the  drug  are  injected,  it  is  not  wise  to  have  them  closer 
together. 

The  After-effects  of  Concentrated  Injections  of 
Novarsenobenzol 

AsRavaut  has  shown,  the  after-effects  of  concentrated 
injections  of  novarsenobenzol  are  generally  very  slight. 

If  the  patient's  temperature  is  taken  carefully 
every  three  hours,  it  will  frequently  be  found  that  a 
rise  begins  six  to  eight  hours  after  the  injection. 
This  rise  of  temperature,  which  is  quite  as  high  after 
dilute  injections,  is  more  intense  after  the  first  injec- 
tion than  after  subsequent  ones  ;  it  is  specially 
marked  in  patients  suffering  from  secondary  symp- 
toms, who  have  been  recently  subjected  to  mercurial 
or  arsenical  treatment.  It  is  generally  absent  after 
subsequent  injections. 


TREATMENT  OF  SYPHILIS  029 

The  temperature  may  rise  to  40°  C,  but  as  a  rule  does 
not  exceed  38°,  and  falls  at  the  end  of  6  to  8  hours. 

This  early  febrile  reaction,  due  to  the  effect  of  the 
drug  on  the  treponema,  must  be  distinguished  from 
a  delayed  reaction,  occurring  the  day  after,  or  two 
days  after,  the  injection,  which  rarely  exceeds  39*5°, 
does  not  last  beyond  twenty-four  hours,  and  seems 
due  to  toxic  phenomena. 

With  certain  patients,  the  injection  of  novarseno- 
benzol  is  followed  by  a  slight  fall  of  temperature, 
below  37°,  some  hours  after  the  injection.  This  is 
much  more  frequent  after  the  third  and  following  in- 
jections than  after  the  first. 

In  many  patients  the  rise  of  temperature  is  not 
accompanied  by  any  noticeable  malaise.  In  others 
there  is  headache,  usually  mild.  This  headache  is 
of  little  importance  unless  it  increases  with  subse- 
quent injections  of  larger  doses. 

Also,  nausea  and  vomiting  are  not  exceptional  after 
the  first  injection,  which  they  follow  almost  immedi- 
ately, but  are  rare  after  subsequent  ones. 

Some  patients  suffer  from  diarrhoea  on  the  night 
following  the  injection,  but  this  is  rarely  severe,  al- 
though sometimes  sanguinolent. 

The  following  are  the  after-effects  of  injections 
observed  in  my  clinic,  where  the  injections  are  always 
made  in  concentrated  solutions. 

The  injections  are  made  between  10  a.m.  and  noon, 
the  patient  resting  quietly  afterwards  and  only  taking 
a  small  quantity  of  liquid.  The  temperature  taken 
in  the  axilla  every  3  hours  from  3  p.m.  did  not  exceed 
37'5°.  i.e.  a  figure  which  may  be  regarded  as  normal 
in  80%  of  the  cases  ;  in  32%  it  remained  below  37°. 
With  certain  patients  it  rose  to  37*2°  or  37 '3°  at  3  p.m., 
reaching  its  maximum  at  6  p.m.,  then  falling  to  37° 
at  9  p.m.,  and  remaining  at  that  figure  during  the 
night.  With  other  patients  it  reached  its  maximum 
at  3  p.m.  ;    then  feU  to  37°  at  9  p.m.  and  remained 


630  SYPHILIS   AND   THE  ARMY 

below  37°  during  the  night  or  at  6  p.m.  These  patients 
experienced  no  trouble  or  discomfort  of  any  kind. 

In  18%  of  the  cases  the  temperature  rose  above 
37 '5  °  but  did  not  exceed  38*5°  ;  this  rise  was  generally 
of  short  duration,  and  reached  its  maximum  at  3  p.m. 
or  6  p.m.  ;  the  patients  often  had  no  malaise,  but 
some  had  a  slight  rigor,  passing  headache,  or  some 
nausea.  These  febrile  attacks  were  observed  especially 
in  patients  who  had  intense  secondary  cutaneous 
manifestations.  In  one  patient  I  saw  a  generalised 
scarlatiniform  eruption ;  in  another  an  urticarial 
eruption  a  few  minutes  after  the  injection. 

In  2%  of  the  cases  there  was  marked  rise  of  tem- 
perature, reaching  40°  C.  at  the  same  time  that  the 
patients  suffered  from  rigors,  headache,  and  nausea, 
which  were  more  intense  than  in  the  preceding  cases, 
but  only  of  short  duration. 

Such  are  the  reactions,  which  may  be  called  normal, 
after  concentrated  injections  of  novarsenobenzol  :  they 
have  no  real  importance,  and  the  fear  of  them  should 
not  prevent  recourse  to  the  drug.  The  attenuating 
influence  that  previous  mercurial  treatment  has  on 
them  should  make  one  precede  the  injections  of  nov- 
arsenobenzol by  mercurial  treatment  whenever  pos- 
sible.   I  shall  again  revert  to  this  point. 

Other  accidents  may,  however,  result  from  this 
medication.  They  are  similar  to  those  observed  with 
other  methods  of  treatment  by  arsenobenzol  or  nov- 
arsenobenzol. These  are  the  accidents  which  have  so 
frightened  certain  medical  men,  and  compromised  the 
arsenical  treatment  of  sjrphilis.  They  are  much  more 
rare  with  concentrated  injections  than  with  other 
methods.     All  the  same,  they  must  be  described  here. 

The  Serious  Accidents  of  Arsenobenzol  and  Novarsenobenzol 

It  is  impossible  to  separate  the  accidents  caused 
by  novarsenobenzol  from  those  produced  by  arseno- 


TREATMENT   OF   SYPHILIS  631 

benzol ;  although  much  less  frequent  with  novar- 
senobenzol,  they  are  of  the  same  order  and  may  be  of 
equal  gravity. 

The  conditions  of  development  of  these  accidents 
are  multiple,  their  pathogeny  is  complex,  and  still  a 
matter  of  dispute.  Their  interpretation  has  given 
rise  to  discussions,  sometimes  acrimonious,  into  the 
details  of  which  I  cannot  enter  without  exceeding  the 
limits  of  this  book.  I  shall  content  myself  with  giving 
a  brief  summary  of  the  most  important  of  them. 

It  must  be  remarked,  first  of  all,  that  certain  of 
these  accidents  cannot  be  attributed  to  the  drug,  but 
to  ignorance  of  its  contra-indications.  It  would  be 
impossible  to-day  to  include,  amongst  accidents  of 
the  medication,  the  serious  consequences  which  may 
result  from  its  use,  especially  in  high  doses,  in  subjects 
suffering  from  grave  lesions  of  the  heart,  liver,  kidneys, 
and  in  cachectic  patients.  In  these  pathological  con- 
ditions, the  administration  of  arsenic  is  contra-indi- 
cated. 

Again,  the  method  cannot  be  blamed  for  the  fatal 
results  of  injections  made  with  arsenobenzol,  the 
composition  of  which  has  changed  from  contact  with 
the  atmosphere,  or  with  solutions  prepared  in  advance, 
the  toxicity  of  which  results  from  chemical  trans- 
formations of  the  arsenobenzol. 

The  reduction  of  the  amount  of  liquid  injected  has 
eliminated  the  noxious  action  of  the  water  and  of  its 
chemical  impurities  ;  the  substitution  of  novarseno- 
benzol  for  arsenobenzol  has  done  away  with  the 
accidents  produced  by  the  insufficiency  of  alkalinisation 
of  the  solutions  of  the  original  product. 

The  uncertainties  of  dosage  which  always  occur  on 
the  first  appearance  of  any  new  drug  have  long 
ceased  ;  the  excessive  doses  preferred  by  some  authors 
have  been  the  cause  of  accidents,  which  no  longer 
happen  with  those  in  use  at  the  present  time. 

The  number  of  serious  accidents,  and  especially  of 


632  SYPHILIS  AND   THE   ARMY 

deaths,  tends  to  diminish  more  and  more,  and  is 
infinitely  less,  especially  with  the  method  of  con- 
centrated injections,  than  during  the  first  years  in 
which  arsenobenzol  was  employed. 

The  serious  accidents  caused  by  arsenobenzol  and 
novarsenobenzol  specially  affect  the  nervous  system. 

The  gravest  of  these  accidents  takes  the  form  of 
acute  encephalitis  ;  it  appears  sometimes  after  the  first 
injection,  more  often  after  the  second,  and  rarely 
after  the  subsequent  ones  ;  it  generally  begins  in  the 
three  first  days  following  the  injection,  rarely  later. 

It  is  characterised  by  severe  headache,  rise  of 
temperature,  facial  congestion,  delirium,  followed  by 
coma,  repeated  epileptiform  attacks,  and  vomiting, 
generally  leading  to  death  within  a  few  hours. 

At  the  post-mortem,  intense  hypersemia  of  most  of 
the  organs  is  found,  and  particularly  punctiform 
haemorrhages  in  the  cerebral  substance  ;  at  the  same 
time  lesions  of  acute  nephritis  are  often  present. 

The  great  majority  of  deaths  following  the  adminis- 
tration of  arsenobenzol,  and  more  rarely  novarseno- 
l)enzol,  belong  to  this  type.  It  occurs  not  only  in 
patients  suffering  from  visceral  troubles,  but  also 
sometimes  in  healthy,  young,  and  vigorous  subjects, 
in  whom  there  was  absolutely  no  warning  of  what 
was  about  to  happen,  and  this  after  moderate  doses 
of  the  drug.  It  must  be  recognised,  however,  that 
inexplicable  deaths  from  arsenobenzol  have  become  the 
exception. 

Encephalitis  appears  more  frequently  after  the 
second  injection  of  arsenobenzol  than  after  the  first. 
Its  development  must  be  si)ecially  suspected  in  subjects 
who,  after  the  first  injection,  presented  an  intense 
febrile  reaction,  facial  congestion,  the  phenomena 
described  by  Milian  under  the  name  of  nitritoid  crises, 
and  especially  morbilliform  or  scarlatiniform  cutaneous 
eruptions. 

It  is  advisable  with  patients  who  have  suffered  from 


TREATMENT  OF  SYPHILIS  635 

reactions  of  this  kind,  after  the  first  injection,  to  sus- 
pend treatment,  or  at  least  only  to  employ  moderate 
doses. 

Besides  this  grave  form,  there  is  a  series  of  pheno- 
mena, of  a  less  tragic  character,  described  under  the 
name  of  neuro-r elapses.  These  consist  chiefly  in  paraly- 
sis of  the  cranial  nerves. 

They  appear  some  weeks  after  treatment  is  finished, 
and  are  preceded,  during  some  days  or  weeks,  by  head- 
ache of  varying  intensity,  diffuse  or  predominating  on 
the  side  of  which  the  paralysis  is  situated,  and  pains 
in  the  nape  of  the  neck,  \jI\q  back,  or  limbs.  According 
to  the  statistics  of  Benario,  this  paralysis  affects  the 
auditory  nerve  in  44' 5%  of  the  cases,  the  optic  nerve 
in  302%  ,the  oculomotor  nerve  in  7*4%  and  the  facial 
nerve  in  7%. 

Affection  of  the  auditory  nerve  is  manifested  by 
tinnitus,  auditory  hallucinations,  unilateral  or  bilateral 
deafness,  which  may  be  accompanied  or  not  by  slight 
vertigo  and  rarely  by  vomiting. 

Lesions  of  the  optic  nerve  result  in  optic  neuritis, 
neuro-retinitis  or  retinitis  with  stasis  of  the  pupil,  often 
without  very  pronounced  functional  troubles. 

Lesions  of  the  oculomotor  and  facial  nerves  give 
rise  to  paralysis  of  the  corresponding  muscles. 

The  unilateral  or  bilateral  lesions  sometimes  affect 
several  cranial  nerves  simultaneously;  hence  the  varietj^ 
of  clinical  syndromes,  sometimes  rendered  more 
complex  by  the  co-existence  of  lesions  of  the  spinal 
nerves  :  paralysis  of  the  type  of  Landry's  disease, 
polyneuritis,  intercostal  neuralgia,  etc. 

Lumbar  puncture  reveals  abundant  lymphocytosis 
of  the  cerebro-spinal  fluid. 

Functional  disorders  generally  recover  after  a 
variable  period  ;  but  auditory  affections  may  persist 
indefinitely. 

These  different  lesions  result  from  compression  of 
the  cranial  nerves  by  basilar  meningitis,  often  associated 


634  SYPHILIS  AND   THE  ARMY 

with  latent  spinal  meningitis,  which  is  only  revealed 
by  lumbar  puncture. 

These  facts  have  been  the  subject  of  various  inter- 
pretations. When  arsenobenzol  was  first  used,  their 
frequency  caused  them  to  be  attributed  solely  to  the 
toxic  action  of  the  drug.  It  was  soon  remarked,  how- 
ever, that  lesions  of  the  same  kind  were  observed  in 
syphilitics  before  the  use  of  arsenobenzol,  only  less 
frequently  ;  and,  on  the  other  hand,  that  they  were 
only  observed  amongst  syphilitics  and  never  appeared 
in  piatients  treated  with  arsenobenzol  for  affections 
independent  of  syphilis.  Attributed  to  the  neuro- 
trophic action  of  arsenobenzol,  they  were  soon  put 
down  to  the  action  of  the  pathogenic  agent  of  syphilis, 
hence  the  name  of  neuro-relapses,  which  has  been  given 
them.  This  denomination  is  disputable  because  it  is 
not  a  question  of  the  recurrence  of  previously  existing 
lesions,  but  it  has  entered  into  current  language.  It 
is  recognised  to-day  almost  unanimously  that,  if  the 
lesions  are  of  a  syphilitic  nature,  arsenobenzol  may 
favour  their  development. 

As  Ravaut  has  shown,  syphilis  frequently  causes 
meningeal  lesions,  which  remain  latent  clinically,  and 
are  only  revealed  by  changes  in  the  cerebro-spinal 
fluid  (lymphocytosis,  albumin),  which  are  exacerbated 
by  arsenobenzol,  resulting  in  neuro-recurrent  pheno- 
mena. The  neurotropism  of  arsenobenzol,  which  has 
been  invoked  to  explain  the  production  of  these 
accidents,  does  not  exist,  according  to  Ravaut,  unless 
the  nervous  system  is  already  invaded  by  the  treponema. 
This  explains  why  these  lesions  are  observed  especially 
in  syphilitics  treated  too  late  with  arsenobenzol,  at  a 
period  when  the  treponema  has  already  reached  the 
nervous  system,  and  do  not  occur  in  patients  sub- 
mitted to  arsenical  injections  from  the  very  onset  of 
the  chancre. 

The  frequency  of  these  lesions  is  diminished  by 
associating    mercury    with    arsenobenzol,    especially 


TREATMENT  OF  SYPHILIS  635 

when  the  arsenobenzol  treatment   is  preceded  by  a 
course  of  mercury. 

The  various  organs  may  present  more  or  less  acute 
reactions  under  the  influence  of  arsenobenzol. 

Icterus  is  sometimes  observed ;  it  appears  to  be 
favoured  by  renal  insufficiency.  It  often  accompanies 
fatal  encephalitis,  but  may  also  exist  alone.  It  is 
presented  under  very  variable  aspects,  from  a  rapidly 
curable  form  to  a  fatal  one,  with  symptoms  of  grave 
icterus  (acute  cirrhosis,  yellow  atrophy  of  the  liver). 
The  pathogenesis  of  the  icterus  of  arsenobenzol  has 
not  been  definitely  elucidated. 

Albuminuria  appears  in  some  cases  to  be  provoked 
by  arsenobenzol.  It  often  happens  that  long-standing 
albuminuria  may  be  exaggerated  or  reappear  ;  it  may 
persist  and  be  accompanied  by  ursemic  troubles  ;  it 
ceases  if  arsenical  treatment  is  at  once  interrupted. 

Gastro-intestinal  disorders  which  are  usually  hardly 
noticeable,  sometimes  attain  a  certain  intensity : 
repeated  vomiting,  copious  diarrhoea. 

Cardiac  disturbance  rarely  becomes  pronounced, 
except  in  the  case  of  a  lesion  of  the  heart,  and  especially 
of  aortic  aneurism,  which  forms  a  contra-indication 
to  the  use  of  the  drug.  It  is  usually  limited  to  palpita- 
tions, or  at  most  lipothymia,  which  forms  part  of  the 
nitritoid  crises. 

Cutaneous  eruptions  of  an  erythematous,  rubeoli- 
form,  or  more  frequently  scarlatiniform  type  may 
occur  after  injections  of  arsenobenzol,  usually  about 
the  second  day ;  they  constitute  a  sign  of  severe 
intoxication.  Some  cases  of  generalised  exfoliative 
erythrodermia  have  occurred  from  the  use  of  arseno- 
benzol. 

To  sum  up,  multiple,  grave,  even  fatal  lesions  may 
follow  injections  of  arsenobenzol  and  of  novarseno- 
benzol.  The  pathogenesis  of  some  of  these  seems  to 
be  established  ;  in  the  case  of  nervous  lesions,  the 
phenomena  are  comparable  to  Herxheimer's  Reaction, 


636  SYPHILIS  AND  THE  ARMY 

and  are  probably  due  to  the  action  of  the  arsenical 
products  on  tissues  already  inhabited  or  altered  by 
the  spirochsete.  In  others,  the  pathogenesis  remains 
obscure. 

One  fact  has  been  established,  namely,  that  these 
disturbances  are  less  frequent  and  not  so  grave  with 
novarsenobenzol  as  they  are  with  arsenobenzol,  and 
that  concentrated  injections  still  further  reduce  their 
number  and  gravity. 

It  is  none  the  less  true  that  they  may  exceptionally 
follow  injections  made  quite  correctly,  and  without 
there  being  anything  to  indicate  their  approach. 

Fear  of  these  disturbances  must,  nevertheless,  not 
prevent  recourse  to  arsenical  medication,  especially 
in  the  case  of  young  patients  ;  for  indeed  this  some- 
times protects  the  patient  from  syphilitic  manifesta- 
tions, which  are  often  graver  and  in  any  case  more 
frequent. 

Other  Arsenical  Preparations 

Various  other  products  with  an  arsenical  basis 
have  been  proposed  for  the  treatment  of  syphilis. 

I  may  recall  the  fact  that,  before  Ehrlich's  discovery, 
benzo-sulpho-para-aminophenylarsinate  of  sodium,  sold 
under  the  name  of  hectine,  had  a  certain  vogue  ;  its 
activity  being  much  lower  than  that  of  arsenobenzol 
and  novarsenobenzol,  preference  has  been  given  tb 
these  two  last  substances.  It  has  no  special  indica- 
tion in  army  medicine  and  cannot  replace  novarseno- 
benzol. The  same  applies  to  its  combination  with 
mercury,  under  the  name  of  hectargyre. 

Mouneyrat  discovered  another  arsenical  compound, 
tetraoxydiphosphaminodiarsenobenzene,  described  by 
the  number  1116,  which  is  sold  under  the  name  of 
galyl.  This  substance  is  presented  in  the  form  of  a 
yellow  powder,  without  either  smell  or  taste,  insoluble 
in  water  and  the  majority  of  neutral  solvents.  When 
placed  in  a  weak  solution  of  carbonate  of  soda,   it 


TREATMENT  OF  SYPHILIS  637 

dissolves  instantly  and  yields  a  brown  or  yellowish 
brown  fluid.  According  to  its  promoters,  galyl  is 
less  toxic  than  arsenobenzol,  causes  no  congestive 
phenomena,  and  is  tolerated  well.  They  say,  it  should 
be  used  for  man  in  a  total  dose  of  1"50  gr.  spread  over 
three  injections  with  an  interval  of  eight  days  between 
each. 

Whatever  its  activity  or  innocuousness,  this  product, 
like  the  original  arsenobenzol,  Ehrlich's  "  606,"  has  the 
inconvenience  of  not  dissolving,  except  in  an  alkaline 
medium.  If  the  dosage  of  carbonate  of  soda  is  not 
absolutely  accurate,  and  this  seems  to  offer  some 
difficulty,  either  an  imperfect  solution  is  obtained  or 
a  hyperalkaline  fluid,  which  irritates  the  walls  of  the 
veins  and  causes  painful  indurations,  independently 
of  any  operative  unskilfulness.  For  this  reason,  this 
drug  does  not  seem  to  me  to  be  suitable  for  army 
medicine. 

More  recently,  Danysz  proposed  a  complex  arsenical 
compound  for  the  treatment  of  syphilis,  containing 
antimony  and  silver,  stibico-argentic  sulphate  of  dioxy- 
diaminoarsenobenzol,  described  by  the  number  102, 
and  placed  on  the  market  under  the  name  of  luargol. 
The  compound  is  presented  in  the  form  of  a  yellowish- 
orange  powder,  which,  like  other  products  of  the 
arsenobenzol  series,  has  to  be  preserved  in  hermetically 
sealed  vacuum  tubes.  It  is  insoluble  in  water,  but 
soluble  in  dilute  alkaline  fluids,  forming  a  very  dark 
brown  solution,  which  changes  rapidly  in  a  bright 
light,  and  more  slowly  in  the  dark.  This  solution  must 
he  filtered  before  use.  Its  toxicity  appears  to  be  lower 
than  that  of  arsenobenzol,  and  its  greater  activity 
enables  one  to  obtain  therapeutic  effects  comparable 
to  those  of  novarsenobenzol,  with  smaller  doses. 
Owing  to  its  weak  toxicity,  it  seems  to  me  to  be  very 
useful  in  the  treatment  of  syphilis  in  exhausted,  over- 
worked, and  elderly  patients. 

Luargol  has  the  inconveniences  of  all  substances 


638  SYPHILIS   AND   THE   ARMY 

which  only  dissolve  in  an  alkaline  medium ;  even  in 
the  hands  of  experts,  it  sometimes  produces  venous 
changes,  distension  of  the  vein  at  the  moment  of 
injection,  with  subsequent  pain  and  induration  of  the 
vein  ;  it  cannot,  therefore,  be  recommended  as  a 
suitable  drug  for  the  Army  at  present. 

To  sum  up,  the  different  agents  of  arsenical  medica- 
tion, in  experienced  hands,  may  give  satisfactory  results 
in  the  treatment  of  syphilis.  Those  who  have  had 
much  experience  with  one  of  these  substances  may 
prefer  it  to  the  others.  In  army  practice,  where  it 
is  necessary  to  treat  patients  actively,  rapidly,  and 
with  the  least  possible  risk  of  local  and  general  disturb- 
ances, in  my  opinion,  with  the  limited  material  at  our 
disposal  in  the  medical  centres,  one  can  only  recom- 
mend novarsenobenzol  for  the  routine  administration 
of  arsenical  treatment. 

Association  of  Mercury  and  Arsenic 

When  intensive  arsenical  medication  was  first  com- 
menced, Ehrlich  announced  that  syphilis  was  sterilised 
by  arsenobenzol  ;  one  might  have  believed  that  mer- 
cury was  going  to  be  removed  from  the  list  of  anti- 
syphilitic  drugs. 

To-day,  even,  some  medical  men  believe  that 
arsenobenzol  suffices  for  the  treatment  of  syphilis 
from  its  onset  to  its  latest  periods.  Their  number 
has  never  been  very  large,  and  I  believe  that  it  is 
diminishing  more  and  more. 

As  a  matter  of  fact,  all  medical  men,  even  those  who 
have  retained  the  greatest  belief  in  arsenobenzol,  have 
seen  patients  thus  treated — not  only  with  novarseno- 
benzol, which  may  be  less  active,  but  also  Ehrlich's 
salvarsan — with  high  doses  and  repeated  injections, 
who  have,  nevertheless,  shown  grave  syphilitic  mani- 
festations, often  a  short  time  after  the  last  injections. 
Patients,   having  first  received  3   to   5  grammes   of 


TREATMENT  OF   SYPHILIS  639 

arsenobenzol  in  6  to  8  injections,  then  one  or  two 
series  of  similar  injections,  who  had  had  no  lesion 
beyond  a  chancre,  have  come  to  consult  me  for  roseola 
of  the  type  of  recurrent  roseola,  or  for  a  papulo- 
tubercular  syphilide.  I  repeat,  every  one  has  seen 
similar  facts,  the  reproduction  of  which  has  become 
significant. 

No  doubt  syphilitics  have  shown  grave  syphilitic 
disturbances  directly  after  mercurial  treatment,  even 
during  its  course,  and  after  it  had  been  followed 
carefully  for  what  was  regarded  as  an  adequate  period. 

But,  having  regard  to  the  relative  number  of  patients 
treated  intensively  with  arsenobenzol,  the  cases  are 
much  more  frequent  in  which  this  drug  has  not  pre- 
vented later  disturbances. 

Hence,  the  majority  of  sy philologists  are  of  opinion 
that  it  is  at  least  advantageous — most  say  a  necessity 
— to  complete  the  arsenical  treatment  of  syphilis  by 
a  course  of  mercury. 

By  means  of  this  combined  method  the  patient 
benefits,  on  the  one  hand,  by  the  quickness  of  action 
of  the  arsenobenzol,  the  rapid  healing  of  lesions,  and, 
in  cases  of  primary  or  secondary  syphilis,  by  its 
markedly  retarding  action  of  secondary  manifesta- 
tions ;  on  the  other  hand,  by  the  greater  security  offered 
by  mercurial  treatment  as  a  prophylactic  measure 
against  later  manifestations. 

The  association  of  mercury  and  arsenobenzol  has 
another  advantage,  upon  which  Ravaut  has  rightly 
insisted.  If  administered  before  the  arsenical  treat- 
ment, mercury  kills  a  certain  number  of  treponemas; 
the  first  injection  of  arsenobenzol  will  therefore  destroy 
a  smaller  quantity  of  treponemas,  and  consequently 
the  proportion  of  bacteriolytic  products  distributed 
in  the  circulation  will  be  sensibly  diminished.  The 
result  is  that  the  fever,  the  intensity  of  which  is  directly 
due  to  intoxication  by  the  bacteriolytic  products  of 
the  treponema,  is  less  in  patients  first  treated  by  large 


640  SYPHILIS  AND   THE   ARMY 

doses  of  mercury.*  This  result  is  particularly  im- 
portant to  obtain  in  the  secondary  period,  with 
cutaneous  and  mucous  manifestations  which  are  rich 
in  treponemas. 

For  these  reasons  there  is  almost  complete  unanimity 
amongst  syphilologists  as  to  the  necessity  of  combining 
mercurial  and  arsenobenzol  treatment. 

But  how  are  these  two  drugs  to  be  combined  ? 
Must  they  be  prescribed  simultaneously,  alternatively 
or  successively  ?  Here,  as  for  the  dosage  of  the  drugs, 
all  kinds  of  opinions  are  expressed  ;  each  syphilologist 
has  his  own  method,  derived  from  his  theoretical 
conceptions  of  the  effects  of  the  drugs  and  from  the 
good  or  bad  results  h^  has  witnessed. 

Some  authors  are  afraid  of  using  mercury  at  the 
same  time  as  giving  arsenical  treatment,  and  dreading 
accidents,  especially  with  secondary  syphilitics,  do 
not  begin  arsenobenzol  until  after  a  prolonged  mercurial 
treatment,  stopping  the  mercury  directly  they  com- 
mence using  arsenobenzol. 

The  majority  of  syphilologists  consider  that  these 
fears  are  exaggerated,  and  that  the  two  drugs  may 
be  alternated  and  combined  without  danger. 

For  my  own  part,  I  have  interposed  injections  of 
cyanide  of  mercury  between  injections  of  arsenobenzol 
in  hundreds  of  cases,  and  have  not  seen  any  bad  effects. 
I  have,  therefore,  no  scruple  in  preferring  this  method 
of  treatment. 

In  military  practice  it  has  the  advantage  over  the 
successive  or  alternative  use  of  the  two  drugs  of  reducing 
the  duration  of  treatment,  the  intervals  between  the 
injections  of  arsenobenzol  being  made  use  of  for  the 
mercurial  treatment,  or  at  least  for  a  considerable  part 
of  this  treatment.  During  the  primary  and  secondary 
periods,  when  contagious  lesions  compel  the  patient 
to  be  sent  to  hospital,  it  is  then  possible,  without  loss 
of  time,  to  combine  the  arsenical   treatment  simul- 

*  Ravaut  and  Scheikevitch,  loc.  cit. 


TREATMENT  OF  SYPHILIS  641 

taneously  with  the  most  active  mercurial  treatment. 
In  this  way,  the  whole  weight  of  the  attack  is  at  once 
brought  to  bear  upon  the  syphilitic  infection  from  it& 
onset. 

SCHEME  FOR  THE  TREATMENT  OF  SYPHHJS  IN 
THE  ARMY  AT  THE  DIFFERENT  PERIODS  OP 
INFECTION 

After  describing  the  different  methods  of  treatment 
of  syphilis,  their  advantages,  disadvantages,  and 
dangers,  it  is  necessary  to  consider  the  course  to  be 
followed  in  the  treatment  of  syphilis  in  the  Army. 

Here,  again,  it  is  only  a  question  of  formulating 
routine  treatment  of  syphilis,  which  the  medical  man 
must  modify,  according  to  the  particular  conditions  of 
the  patients  and  of  their  disease.  With  regard  to 
military  patients  collectively,  relatively  few  differences^ 
are  found  in  general  conditions  of  age.  health,  physical 
resistance,  etc.  Syphilitic  manifestations  being  gener- 
ally observed  in  them  at  an  early  stage  and  under  fairly 
similar  forms,  this  routine  treatment  will  have  more 
chance  of  respoiiding  to  the  indications  of  the  great 
majority  of  cases  than  it  would  in  the  case  of  any 
other  group  of  patients. 

I  again  repeat,  that  the  treatment  must  be  instituted 
in  such  a  way  that  it  will  reduce  to  a  minimum  the 
ineffectiveness  of  the  soldier.  In  order  to  do  this, 
every  soldier  suffering  from  contagious  syphilitic  lesions 
— sent  to  hospital  on  account  of  contagion  and  neces- 
sarily isolated — should,  while  in  hospital,  be  subjected 
to  energetic  treatment  capable  at  the  same  time  of 
causing  rapid  cicatrisation  of  the  contagious  lesions 
and  of  combating  the  general  infection,  and  preventing, 
or  at  any  rate  attenuating,  subsequent  manifestations 
treatment  by  attack  and  barrage  against  syphilis. 

Further,  when  the  syphilitic  patient  has  left  hospital, 
he  should  continue  treatment  when  with  his  unit,  in. 


642  SYPHILIS  AND  THE  ARMY 

order  to  prevent  relapses  of  the  disease  at  a  more  or 
less  distant  date  :  continued  treatment,  prevention  of 
later  disturbances. 

I  shall  only  describe  the  treatment  of  syphilis  at  the 
chancral  period  and  at  the  secondary  period ;  tertiarj^ 
disturbances  and  the  sequelae  of  syphilis  play  only  a 
small  part  in  war  syphilology. 

Period  of  the  Chancre. — Once  the  diagnosis  of 
chancre  has  been  undoubtedly  established,  the  syphilitic 
should  be  subjected  to  injections  of  novarsenobenzol 
with  as  little  delay  as  possible,  and  sent  to  hospital  for 
that,  as  well  as  to  put  him  out  of  the  way  of  doing 
any  harm. 

It  is  useful,  but  not  absolutely  indispensable,  to 
precede  the  arsenical  treatment  by  two  or  three  intra- 
venous injections  of  mercury  :  I  say  useful,  because 
I  have  often  seen  the  chancre  partly  cicatrise  under  the 
influence  of  these  injections  alone,  and  also  because  a 
febrile  reaction  is  sometimes  produced  after  the  in- 
jection of  arsenobenzol,  and  this  reaction  is  attenuated 
by  the  initial  injections  of  mercury. 

After  these  injections,  one  of  novarsenobenzol  in 
a  dose  of  45  centigrammes  is  given  ;  eight  days  later, 
an  injection  of  60  centigrammes  of  novarsenobenzol. 
//  imperative,  arsenical  treatment  can  be  left  at  that. 

Nevertheless,  when  the  chancre  has  not  completely 
cicatrised  4  or  5  days  after  the  second  injection  of 
arsenobenzol,  or  if  the  initial  dimensions  of  the  chancre 
were  considerable,  or  accompanied  by  pronounced 
adenopathy,  or  had  not  been  treated  until  after  15 
to  20  days,  it  is  necessary  to  make  a  third  injection 
8  days  after  the  second,  of  0  60  gr.  of  novarseno- 
benzol. In  any  case,  if  military  duties  do  not  prevent 
it,  it  is  advisable  to  make  this  third  injection. 

In  the  intervals  between  the  novarsenobenzol  in- 
jections, an  intravenous  injection  of  cyanide  of  mercury 
{\  centigramme)  is  given  daily  or  every  other  day  ; 
12  to  15  injections  in  all. 


TREATMENT   OF   SYPHILIS  643 

As  it  is  preferable  not  to  make  the  cyanide  injection 
on  the  day  following  the  injection  of  arsenobenzol, 
treatment  lasts  altogether  18  to  24  days. 

On  condition  that  it  is  followed  by  regular  treatment 
by  mercurial  pills,  in  the  way  that  will  be  described 
later  on,  this  is  sufficient,  in  the  great  majority  of  cases, 
to  protect  the  man  from  secondary  disturbances  :  I 
had  practised  this  method  some  time  before  the  war 
with  a  certain  number  of  syphilitics,  and  have  been 
able  to  observe  the  results. 

In  any  case,  if  syphilitic  manifestations  appear  later^ 
they  are  hardly  likely  to  be  of  any  considerable  in- 
tensity. 

As  regards  tertiary  affections,  I  cannot  affirm  that 
they  need  no  longer  be  feared,  but  is  there  any  other 
method  of  treatment  by  arsenobenzol  in  larger  and 
oftener  repeated  doses  that  is  a  certain  protection  ? 

I  must  mention  that,  before  subjecting  the  patient 
to  injections  of  cyanide  of  mercury,  his  teeth  must  be 
examined,  and  attended  to,  if  necessary. 

At  the  same  time  as  this  internal  treatment,  it  is 
almost  unnecessary  to  prescribe  local  treatment  of 
the  chancre  :  washing  in  boiled  water,  dressings  of 
wool  dipped  in  boiling  water,  or,  if  desired,  applica- 
tions of  powder  of  sub-nitrate  of  bismuth  are  sufficient 
to  guarantee  its  cleanliness  and  prevent  infection. 
Calomel  powder  or  calomel  ointment  should  not 'be 
used,  as  they  cause  irritation.  Touching  or  painting 
with  nitrate  of  silver  should  also  be  avoided;  it  is 
useless  and  does  not  visibly  hasten  the  cure  of  chancres 
treated  by  arsenobenzol,  and,  in  a  general  way,  the 
use  of  antiseptics  should  be  dispensed  with. 

In  chancres  of  the  urethra  local  treatment  also  consists 
in  washing  with  boiled  water.  I  do  not  advise  that 
any  dressings  should  be  introduced  into  the  canal  ; 
the  patient  should  drink  large  quantities  of  fluid  to 
dilute  the  urine  and  render  it  less  irritating. 

Chancres  of  the  lips  should  be  dressed  with  boiled 


644  SYPHILIS  AND  THE  ARMY 

water,  or  covered  with  a  piece  of  thin  and  clean  paper 
{cigarette  paper,  for  instance)  ;  the  lips  should  be 
washed  with  boiled  water  after  each  meal. 

In  chancres  of  the  tonsils  the  throat  should  be  irrigated 
with  physiological  serum  ;  emollient,  carbolic,  or  iodine 
gargles  may  be  used. 

The  Secondary  Period. — Not  only  in  cases  with 
active  secondary  symptoms,  but  also  in  those  where 
the  chancre  is  present,  but  has  been  untreated,  general 
treatment  is  almost  identical  with  that  of  the  period 
of  the  chancre. 

Here,  for  the  reason  already  indicated — attenuation 
of  the  febrile  reaction  induced  by  arsenobenzol — it  is 
highly  important  to  precede  the  novarsenobenzol  in- 
jections by  two,  three  (even  four  if  cutaneous  eruptions 
and  mucous  plaques  are  abundant)  intravenous  in- 
jections of  cyanide  of  mercury.  Then  at  weekly  inter- 
vals, two  or  more,  often  three  injections  of  novarsenobenzol 
are  made  in  the  doses  already  recommended  (0"45, 
060,  and  0*60),  with  interpolated  injections  of  cyanide 
of  mercury,  so  that  15  to  20  centigrammes  of  cyanide 
are  given  during  the  period  of  treatment,  which  lasts 
from  18  to  25  days. 

Once  this  treatment  is  over,  the  patient  must  con- 
tinue treatment  in  his  unit  with  pills  of  protoiodide  of 
mercury. 

While  under  treatment  in  hospital,  secondary 
ulcerous  manifestations  are  attended  to  by  local  treat- 
ment :  washing  of  the  mucous  plaques  in  the  genital 
region  with  Labarraque's  solution  (solution  of  hypo- 
chlorite of  sodium)  in  the  proportion  of  two  to  three 
tablespoons  per  litre  of  water  ;  cauterisation  of  the 
hypertrophic  plaques  every  two  days  with  acid  nitrate 
of  mercury,*  or,  failing  that,  touching  with  a  nitrate  of 

*  Acid  nitrate  of  mercury  is,  without  doubt,  the  most  active  and 
efficacious  caustic  for  ulcerous  lesions  of  secondary  syphilis,  especi- 
ally for  hypertrophic  plaques.  It  must  be  handled  with  care, 
other^sdse  large  ana  deep  eschars  may  be  caused.  Xhe  following 
technique  wiU  guard  against  any  accident :    dip  a  piece  of  cottoxi< 


TREATMENT  OF  SYPHILIS  645 

silver  pencil ;  touching  the  buccal  mucous  plaques 
with  nitrate  of  silver  or  with  a  50%  solution  of  methy- 
lene blue,  slight  touches  of  acid  nitrate  of  mercury  on 
the  hypertrophic  plaques  of  the  lips,  tongue,  etc. 

In  severe  ulcerous  lesions  of  the  skin  (malignant 
syphilides),  which  are  very  rare,  however,  in  military 
practice,  arsenical  treatment  must  be  pushed  still 
further  both  as  regards  dosage  and  duration,  and  must 
be  continued  after  the  ulcerations  are  all  healed.  One 
should  make  5  to  6  injections  of  arsenobenzol  in  doses 
of  0-45,  0-60,  0-60,  075,  090.  At  the  same  time,  syrup 
of  iodide  of  iron  should  be  prescribed,  together  with  a 
nourishing  diet  and  fresh  air. 

Certain  forms  of  cutaneous  lesions  of  the  secondary 
period  often  resist  arsenical  medication,  even  if  in- 
tensive ;  papulous  syphilides  with  small  papules  (folli- 
cular, miliary,  lichenoid,  and   acneiform  syphilides). 
It  is  necessary  in  these  forms  to  repeat  the  injections 
of  novarsenobenzol  and  combine  them  with  intravenous 
injections  of  cyanide  of  mercury.     It  is  sometimes  an 
advantage  to  make  one  or  two  injections  of  calomel, 
and,  when  the  resources  of  the  medical  centre  permit 
this,   to   let  the  patient  have   some   sulphur  baths. 
But,  as  these  lesions  are  of  slow  evolution,  neither 
ulcerated  nor  contagious,  the  man  is  not  prevented 
from  performing  his  military  duties,  and  I  do  not 
think  it  advisable  to  prolong  his  stay  in  hospital.     If, 
at  his  depot,  he  can  obtain  the  necessaiy  attention,  is 
doing  sedentary  work,  or  is  engaged  in  munition  works, 
from  which  he  can  attend,  once  a  week,  for  an  injection 
of  novarsenobenzol,  he  can  be  discharged  from  hospital 
at  the  end  of  15  to  20  days. 

wool  rolled  tightly  around  a  wooden  stick  into  the  solution  of  acid 
nitrate,  press  the  stick  against  the  side  of  the  bottle  to  express  any 
superfluous  fluid,  gently  touch  the  affected  surface  with  the  stick, 
and,  as  soon  as  it  becomes  blenched,  pass  a  thick  plug  of  wadding  full 
of  pure  water  over  the  surface.  Contact  with  the  water  will  at  once 
stop  the  pain  caused  by  the  acid  nitrate,  so  that  cauterisation  is 
much  less  painful  with  it  than  it  is  with  nitrate  of  silver. 


CA6  SYPHILIS   AND   THE   ARMY 

In  the  case  of  a  syphilitic  with  secondary  lesions, 
who  has  already  been  treated  with  arsenobenzol . 
there  need  be  no  hesitation  in  continuing  the  same 
drug  under  the  form  indicated  above,  and  even  in 
pushing  the  doses  still  further,  providing  that  this 
treatment  has  not  caused  symptoms  of  intolerance. 

Some  visceral  manifestations  demand  special  medica- 
tion, even  contra-indicating  the  above  treatment. 

Syphilitic  headache  at  the  beginning  of  the  disease, 
with  nocturnal  predominance,  does  not  often  appear 
to  be  very  severe  amongst  soldiers,  apart  from  those 
who  exaggerate  it  in  the  hope  of  escaping  either  from 
treatment  or  from  their  military  duties. 

Treatment,  according  to  the  foregoing  rules,  generally 
causes  it  to  disappear  rapidly  ;  very  frequently  it 
yields  after  the  first  injection  of  arsenobenzol.  Should 
it  persist  and  prevent  sleep,  iodide  of  potassium  may 
be  given  (1  to  2  grammes  daily)  or  a  mild  hypnotic 
(opium). 

Should  the  headache  be  really  intense  and  persistent, 
it  may  be  well  to  make  a  lumbar  puncture,  the  value 
of  which  would  be  twofold.  In  the  first  place,  it 
often  relieves  the  headache  ;  secondly,  examination 
of  the  cerebro-spinal  fluid  enables  one  to  find  out 
the  condition  of  the  nervous  centres ;  if  there  is 
abundant  lymphocytosis  present,  more  prolonged 
treatment  should  be  instituted,  especially  with  arseno- 
benzol. 

Facial  paralysis,  appearing  in  the  secondary  period, 
with  or  without  previous  arsenical  treatment,  in  itself 
reveals  affection  of  the  nervous  system,  and  requires 
energetic  treatment.  I  consider  it  is  wiser,  when  it 
appears  during  the  course  of  arsenical  treatment,  to 
keep  to  mercury,  in  the  form  of  intravenous  injections 
of  the  cyanide,  or  intramuscular  injections  of  calomel. 
Treatment  should  be  prolonged  till  the  disappearance 
of  the  headache  which  often  accompanies  it,  anci 
until  the  paralytic  symptoms  have  become  attenuated. 


TREATMENT   OF   ."SYPHILIS  647 

Later,  the  patient  should  be  kept  under  prolonged 
medical  supervision  and  treatment. 

Early  syphilitic  hemiplegia  also  demands  energetic- 
treatment,  similar  to  that  T  have  just  described  for 
facial  paralysis.  Although  it  may  be  completely 
cured,  without  sequelae,  it  may  lead  to  temporary  or 
permanent  disablement. 

The  same  applies  to  early  meningitis. 

Iritis  is  much  more  frequent  than  paralysis,  and 
also  necessitates  active  treatment,  both  arsenical  and 
mercurial.  There  should  be  no  hesitation  in  giving 
4,  5,  or  even  6  injections  of  novarsenobenzol,  until 
a  total  dose  of  2'50  gr.  to  3'25  gr.  has  been  reached, 
and  at  the  same  time  large  doses  of  mercury  should  be 
administered  and  continued  during  the  arsenical  cure. 
Local  treatment  should  also  be  instituted,  and  consists 
in  the  use  of  atropine,  alternating  or  not  with  that 
of  eserine.  In  a  case  where  the  patient  cannot  be 
rapidly  subjected  to  examination  by  an  ophthalmic 
surgeon,  in  order  to  prevent  the  formation  of  iritic 
adhesions,  4  to  5  drops  of  the  following  eye-lotion 
should  be  used  daily  by  instillation  : 

Xeutral  sulphate  of  atropine  ....     O'lO  gr. 
Distilled  water        .  .  .  .  .  .10   gr. 

Icterus  of  the  secondary  period  of  syphilis  should 
be  treated  with  mercury  :  intravenous  injections  of 
cyanide  are  nearly  always  tolerated  well,  but  all  the 
same  their  effects  must  be  watched  carefully,  on 
account  of  intestinal  haemorrhage.  In  default  of  these 
injections,  recourse  may  be  had  to  intramuscular  in- 
jections of  soluble  salts,  and  the  internal  use  of  calomel 
in  snfall  doses.  Opinions  differ  as  to  treatment  with 
arsenical  compounds.  Owing  to  the  eclective  toxicity 
of  arsenic  for  the  liver,  I  consider  that  it  is  better  not 
to  have  recourse  to  it  during  the  presence  of  icterus, 
nor  till  the  liver  has  regained  its  normal  volume. 
Also  the  diet  must  be  attended  to  very  carefully. 


648  SYPHILIS  AND  THE  ARMY 

Syphilitic  nephritis,  manifested  by  haematuria  and 
albuminuria,  which  is  often  considerable,  requires 
great  care  in  the  administration  of  active  anti-syphilitic 
drugs. 

If  it  is  evident  that  the  albuminuria  is  due  to  syphilis, 
and  is  not  of  long  standing  and  due  to  pathological 
conditions  prior  to  syphilitic  infection,  anti-syphilitic 
drugs  are  indicated  ;  but,  as  these  medicaments  are 
more  or  less  toxic  for  the  kidney,  and  may  add  their 
action  to  that  of  the  syphilitic  virus  to  form  a  chronic 
and  incurable  lesion,  rapid  but  not  too  intensive 
action  is  required. 

Intravenous  injections  are  followed  by  rapid  elimina- 
tion of  mercury  by  the  kidneys  ;  it  is  dangerous,  there- 
fore, to  give  too  high  doses,  especially  at  the  beginning 
of  treatment.  In  such  cases,  it  is  my  custom  to  give 
the  injections  every  day  in  small  doses,  beginning  with 
00025  gr.  increased  gradually  to  0*005  gr.  and  00075, 
and,  if  the  albuminuria  does  not  increase,  up  to  a 
centigramme  at  the  end  of  eight  to  ten  days.  The 
albuminuria  has  then  generally  decreased  slightly 
and  the  use  of  novarsenobenzol  may  be  commenced ; 
but  only  in  small  doses,  015  gr.  or  0'30  gr.  at  the  maxi- 
mum. While  carefully  watching  the  urine,  the  doses 
of  novarsenobenzol  are  raised  to  0'30  gr.,  0'45  gr., 
0'60  gr.,  the  last  being  repeated  until  a  total  of  250 
gr.  to  3  gr.  has  been  reached. 

At  the  same  time,  the  patient  is  kept  in  bed  until 
the  albuminuria  has  disappeared,  and  put  on  milk 
diet. 

Lesions  of  the  muscles  and  bones  rarely  attain  any 
very  considerable  degree  in  secondary  syphilis,  and 
only  exceptionally  necessitate  any  special  treatment. 
Nevertheless,  osteitis  causes  osteocopic  pains  which 
may  prevent  sleep.  Mercurial,  and  especially  arsenical, 
treatment  acts  very  effectively  on  these  pains. 
Sometimes  however,  it  is  preferable  to  administer 
iodide  of  potassium  ( 1  to  3  grammes  daily)  at  the  same 


TREATMENT   OF  SYPHILIS  649 

time  as  mercury.  Local  applications,  especially  mer- 
curial plasters,  combine  the  resolvent  action  resulting 
from  their  composition  and  the  slight  absorption  of 
mercury  with  an  analgesic  action  of  occlusion.  Some- 
times it  may  be  necessary  to  have  recourse  to  hyp- 
notics :  opiates,  bromide,  and  even  chloral,  at  least 
during  the  early  days  of  treatment,  and  until  this  has 
acted  on  the  lesions. 

Continued  Treatment. — The  preceding  treatment  is 
destined  to  combat  active  syphilitic  manifestations, 
to  hasten  the  disappearance  of  contagious  lesions,  and 
check  syphilitic  infection  so  as  to  attenuate  later 
manifestations.  It  is  insufficient  to  prevent  the  return 
of  syphilis,  or  its  hereditary  influence. 

It  is  necessary,  therefore,  that  it  should  be  followed 
by  complementary  treatment,  and  prolonged  during 
several  years. 

On  leaving  hospital,  the  syphilitic  must  be  informed 
that  it  is  imperative  for  him  to  continue  treatment 
during  an  adequate  period.  To  be  realised  practic- 
ally, this  continued  treatment  must  be  simple,  and  not 
interfere  with  the  performance  of  his  duties. 

In  the  Army  several  conditions  have  to  be  considered. 
At  the  Front  there  is  only  one  method  of  treatment 
which  is  suitable,  the  use  of  pills,  tabloids,  or  cachets 
of  protoiodide  of  mercury,  in  the  dose  of  10  centi- 
grammes of  protoiodide  daily,  in  4  pills.  The  periods 
of  treatment,  as  a  general  rule,  will  be  regulated  in 
the  way  to  be  described  later. 

Should  any  contagious  disturbance  appear,  the 
patient  will  be  again  sent  to  a  venereal  centre. 

Should  a  non-contagious  manifestation  appear, 
which  does  not  prevent  military  service,  the  patient 
should  take  a  larger  dose  of  protoiodide  (five  to  six  pills 
daily)  and  during  a  longer  period,  while  on  duty. 

Sometimes,  however,  when  the  regiment  is  resting 
and  in  the  proximity  of  a  venereal  centre,  or  is  provided 
with  a  competent  medical  man,  the  patient  may  be 


650  SYPHILIS   AND   THE   ARMY 

given  one  or  two  injections  of  arsenobenzol,  or  .some 
soluble  mercurial  injections. 

In  the  depots  and  sedentary  services  preparations  of 
protoiodide  are  also  the  most  suitable  for  continued 
treatment  ;  but  it  is  more  feasible  to  make  use  of 
injection.  Whenever  indicated,  injections  of  arseno- 
benzol  may  be  made  ;  these  only  necessitate  a  day,  or 
half  a  day's,  absence  from  duty.  If  the  doctor  is 
accustomed  to  making  intravenous  injections,  it  will 
be  easy  to  arrange  it.  As  to  intramuscular  injections, 
soluble  or  insoluble,  these  should  be  reserved  for  men 
whose  duty  will  not  be  interfered  with  by  a  slight  and 
temporary  pain  on  walking. 

For  munition  workers,  whose  mode  of  life  differs 
but  little  from  that  of  workmen  in  times  of  peace, 
treatment  is  easier  to  carry  out. 

Whenever  possible,  it  is  advantageous  to  make 
two  or  three  injections  of  novarsenobenzol  in  doses  of 
60  centigrammes,  at  intervals  of  eight  days,  about  two 
months  after  the  initial  treatment  in  hospital.  Each 
of  these  injections  only  necessitates  rest  for  a  day  or 
half  a  day,  and  could  be  made  either  at  the  end  of 
the  day  or  at  the  time  of  the  half- weekly  rest. 

Mercurial  treatment  can  be  carried  out  by  means 
of  pills,  as  with  the  soldiers  at  the  front  ;  but,  in  any 
case,  it  is  preferable  to  give  injections,  either  intra- 
venous of  cyanide,  or  intramuscular  of  soluble  prepara- 
tions, when  the  medical  service  allows  patients  to 
submit,  without  loss  of  time,  to  an  injection  every 
second  day,  or  to  injections  of  grey  oil  when  it  is  only 
possible  to  give  them  once  a  week. 

Continued  mercurial  treatment,  no  matter  what 
preparations  are  used  for  it,  should  be  carried  out,  as 
far  as  possible,  on  the  following  lines,  from  the  point 
of  vie^\'^  of  periodicity  and  duration  :  First,  20  days 
per  month  during  the  3  months  following  hospital 
treatment. 

For  the  next  9  months,   12  to  15  days  per  month. 


TREATMENT  OF  SYPHILIS  G51 

and  during  the  following  year  12  to  15  days  every  two 
months. 

Later  on,  mercurial  treatment  should  be  repeated 
during  2  or  3  years,  twice  a  year  for  40  to  50  days. 

It  must  be  again  emphasised  that,  during  the  course 
of  this  treatment,  the  patient  must  take  care  of  his 
teeth,  and  brush  them  every  day  ;  that  treatment 
must  be  suspended  if  troubles  attributable  to  the 
mercury  occur — salivation,  stomatitis,  diarrhoea — to 
be  again  resumed  later  with  precautions  ;  that,  if 
syjDhilitic  symptoms  appear,  mercurial  treatment  must 
be  reinforced  or  completed  by  injections  of  arsenobenzol 
according  to  the  nature  and  gravity  of  the  disturb- 
ances ;  in  a  word,  it  must  be  adapted  to  the  indications 
presented. 

It  niSLj  be  remarked  that,  in  the  regulation  of  this 
treatment,  I  give  no  place  to  the  indications  furnished 
by  the  Wassermann  Reaction.     Besides  being  difficult 
to    carry  out  regularly  wdth    all  the   patients  during 
the  course  of  their  disease,   I   consider,   with  many 
authors,   that  this  reaction  is  of  no  value  from  the 
point  of  view  of  indication  and  regulation  of  treatment. 
It  is  an  excellent  diagnostic  method  within  the  limits 
where  its  accuracy  can  be  relied  on  ;    but,  whatevei* 
one  may  say,  it  does  not  furnish  a  single  precise  fact 
as  to  the  possibility  of  the  return  of  syphilitic  disturb- 
ances.    It  may  be  negative  in  patients  who,  a  few 
days  previously,  presented  severe  symptoms  ;    again, 
it  may  be  positive  at  a  given  moment,  and  then  become 
negative  without  the  patient  having  received  any  treat- 
ment. 

Having  3'egard,  on  the  one  hand,  to  this  uncertainty, 
and,  on  the  other  hand,  to  the  well  known  preventive 
action  of  mercury  employed  in  the  form  of  successive 
treatments  during  the  first  years  of  infection,  j^atients 
should  be  given  the  benefit  of  repeated  intermittent 
mercurial  treatment  without  paying  any  attention  to 
the  results  of  the  serum-reaction. 


CHAPTER   VI 

TECHNIQUE    OF   INTRAVENOUS   INJECTIONS 

As  we  have  seen  in  the  preceding  chapter,  intravenous 
injections  play  an  important  part  in  the  modern  treat- 
ment of  syphilis.  Although  they  do  not  constitute  a 
method  reserved  exclusively  for  S5rphilis,  and  are 
to-day  largely  used  in  therapeutics,  it  seems  neces- 
sary that  I  should  here  give  details  of  the  technique. 
The  following  description  will,  I  believe,  enable  any 
medical  man,  who  will  follow  it  regularly,  to  perform 
the  injections  without  any  great  difficulty. 

Nothing  is  so  good,  however,  for  perfecting  the 
technique  of  injections  as  frequenting  a  hospital 
where  they  are  performed  constantly. 

Instruments 

The  apparatus  required  for  intravenous  injection  is 
very  simple.  All  the  essentials  are  found  in  every 
medical  centre,  and,  being  constantly  used  for  the 
most  varied  diseases,  they  are  always  kept  in  stock. 

It  includes  : 

(1)  An  all-glass  syringe,  with  a  capacity  of  1  or  2 
cubic  centimetres,  for  injection  of  cyanide  of  mercury, 
and  2  cubic  centimetres  for  concentrated  injections 
of  novarsenobenzol.  In  case  of  urgency,  one  might 
use  a  syringe  of  1  cubic  centimetre  for  the  latter,  when 
30  centigrammes  of  arsenobenzol  are  injected,  and  fill 
it  twice  for  higher  doses.  Syringes  holding  5,  10,  and 
20  cubic  centimetres  may  also  be  used  for  injecting 

652 


INTRAVENOUS  INJECTIONS 


653 


2  cubic  centimetres  of  the  solution,  but  they  necessitate 
the  use  of  an  intermediary  nozzle,  which  may  get 
lost,  and,  owing  to  the  size  of  the  piston,  this  requires 
a  greater  effort  of  pressure  ;  it  is  therefore,  preferable 
to  use  a  syringe  with  a  small  capacity. 

(2)  The  needle.  Any  needle  that  pierces  well  and  is 
not  too  large  is  good,  on  condition  that  the  operator 
knows  how  to  use  it. 

The  bevel  of  the  needle  should  be  as  slight  as  possi- 
ble, so  as  to  avoid  an  accident,  to  which  I  shall  refer 


Fig.  1. — Apparatus  required  for  the  Intravenous  Injection  of 
N  o  var  senob  enzol. 

later  on  ;    but  it  must  not  be  too  flat-nosed,  because 
needles  of  this  kind  pierce  badly. 

I  much  prefer  needles  of  steel  to  those  of  either 
platinum  or  nickel,  as  they  pierce  better  ;  if  they  are 
well  taken  care  of,  i.e.  are  kept  greased,  they  do  not 
become  oxidised  and  last  for  a  long  time  ;  further, 
they  can  be  easily  sharpened,  and  are  not  expensive. 
There  is  no  advantage  in  a  platinum  needle,  especially 
as  for  intravenous  injections  it  has  always  to  be 
sterilised  in  an  autoclave  or  in  boiling  water ;  if 
sterilised  in  a  flame,  there  is  always  danger  of  the 


C54  SYPHILIS   AND   THE   ARMY 

formation  of  carbon  concretions  in   the  bore  of  the 
needle. 

Some  medical  men  have  suggested  various  devices, 
such  as  the  use  of  a  rubber  attachment  to  the 
syringe.  Clement  Simon  *  has  devised  a  bent  at- 
tachment to  the  syringe,  in  order  to  facilitate  the 
introduction  of  the  needle  into  the  vein,  and  allow  of 
its  being  directed  almost  parallel  to  the  skin.  When 
it  is  only  necessary  to  inject  a  small  quantity  of  fluid 
(1  or  2  cubic  centigrammes),  these  arrangements  have 
the  inconvenience  of  making  the  amount  of  drug 
inj  ected  uncertain .  They  have  no  practical  advantage  ; 
they  are  easy  to  lose,  and  difficult  to  replace. 

(3)  A  rubber  tube  for  a  tourniquet. 

(4)  If  the  medical  man  works  alone,  or  with  a  some- 
what inexperienced  assistant,  he  must  have  a  pair  of 
pressure  forceps  to  fix  the  tourniquet. 

(5)  Absorbent  wool. 

(6)  An  antiseptic  fluid  for  disinfecting  the  skin.  1 
advise  the  use  of  alcohol  or  eth^r  for  asepsis  before 
making  the  injection,  because  they  are  colourless, 
and  do  not  cover  up  the  vein,  and  tincture  of  iodine  for 
aseptic  purposes  after  the  injection. 

(7)  The  product  to  be  injected. 

Also,  if  novarsenobenzol  is  to  be  injected  : 

(8)  Distilled  or  boiled  water  for  making  the  solu- 
tion t  ;  and 

(9)  A  small  receptacle  (porcelain  or  glass)  for  making 
the  solution,  although  the  ampoule  containing  the 
drug  may  be  sufficient. 

*  Clement  Simon,  "  Technique  of  Intravenous  Injections "' 
(Journal  de  Medecine  et  de  Chiruryie  pratiques,  June  10th,  1018). 

•(•  As  novarsenobenzol  is  completely  soluble  in  water,  it  is  not 
Jieces.sary  to  filter  the  solution,  and  the  expensive  and  fragile  appara- 
tus provided  for  filtration  is  useless  if  care  is  taken  not  to  aspirate 
the  Aery  last  drops  of  the  solution  into  the  syringe. 

When  boiled  water  is  used,  one  must  be  certain  of  its  filtration 
without  risking  contamination.  Ravaut  has  proposed  a  very 
simple  device  for  this  purpose.  This  consists  in  applying  the 
extremity  of  the  syringe  against  the  wall  of  the  receptacle  in  which 


INTRAVENOUS   INJECTIONS  655 

The  syringe,  needle,  and  receptacle  intended  for 
preparing  the  novarsenobenzol  solution  must  of  course 
be  sterilised,  either  in  a  steriliser  or  by  prolonged 
boiling  in  pure  water.  In  places  where  the  water  is 
very  chalky,  in  order  to  avoid  precipitation  of  carbonate 
of  lime  in  the  needle,  syringe,  or  receptacle,  sterilisation 
riiust  be  effected  either  by  distilled  water,  or  water 
which  has  already  been  boiled,  and  decanted. 


Mode  of  Operation 

The  liquid  to  be  injected  having  been  prepared  and 
aspirated  into  the  syringe  ;  this,  armed  with  the  needle, 
is  placed  on  a  table  close  to  the  operator  ;  it  rests  on  a 
sterilised  compress,  or  simply  on  the  edge  of  the  table 
in  such  a  way  as  to  avoid  contact  with  any  non- 
sterilised  object.  The  table  should  by  preference  be 
to  the  right  of  the  operator. 

He  places  the  patient  opposite  to  him,  seated  on  a 
chair,  or  sits  down  beside  the  bed  in  the  exceptional 
€ases  in  which  the  patient  cannot  get  up.  The 
patient's  arm,  bare  to  the  middle  of  the  biceps,  rests 
either  on  the  knee  of  the  operator,  on  the  edge  of  the 
table,  or,  more  preferably,  is  held  by  the  operator's  left 
hand.  The  rubber  tourniquet  is  applied  at  the 
junction  of  the  middle  and  lower  third  of  the  patient's 
arm,  stretching  it  before  encircling  the  arm.  If  the 
operator  is  alone,  he  clips  the  band  by  means  of 
pressure  forceps,  taking  care  not  to  catch  up  the  skin. 
If  he  has  an  assistant,  the  latter  holds  the  tourniquet 

the  water  has  been  boiled,  interposing  a  tampon  of  wool,  which  has 
al.so  been  boiled,  and  aspirating  slowly ;  the  w'adding  acts  as  a 
filter,  which  the  fluid  is  compelled  to  pass  through  in  order  to  pene- 
trate into  the  sjninge. 

A  glass  tube,  open  at  the  end,  can  also  be  immersed  in  the  recep- 
tacle while  the  water  is  boihng ;  for  example,  the  body  of  a  lorge-sized 
"syringe,  at  the  bottom  of  which  a  tampon  of  wool  has  been  carefully 
placed  :  the  water  passes  through  the  wool  filter  before  flowing 
})erfectly  clear  into  the  upper  part  of  the  tube,  or  it  can  be  aspirated 
with  the  needle. 


Go6 


SYPHILIS  AND   THE  ARMY 


tight  until  the  needle  has  been  inserted  into  the 
vein. 

At  the  same  time,  if  the  veins  are  not  very  prominent, 
the  patient  is  told  to  close  the  fist  or  flex  and  extend 
the  fingers,  so  as  to  make  the  veins  swell.  The  operator, 
or  his  assistant,  rubs  alcohol  or  ether  over  the  bend  of 
the  elbow. 

The  next  step  is  to  select  the  vein  into  which  the 
injection  is  to  be  made  ;  all  veins  at  the  bend  of  the 
elbow,  of  the  lower  part  of  the  arm,  and  upper  part 
of  the  forearm,  may  be  utilised.     With  the  majority 


Fig.  2. — First  stage  of  the  injection. — Position  of  lingers  of  the 
light  hand  holding  the  syringe.  Position  of  left  thumb  holding  the 
vein.  The  syringe  is  directed  in  the  axis  of  the  vein  and  almost 
parallel  to  the  surface  of  the  limbs. 

of  vigorous  men,  all  veins  are  equally  apparent  and 
may  be  used  with  equal  propriety  ;  with  patients 
who  have  already  had  injections,  there  may  be  venous 
indurations,  which  limit  the  extent  of  utilisable  vessels. 
The  operator  chooses  preferably  not  from  amongst  the 
most  visible  and  most  distended  veins,  but  from 
those  which  are  most  swollen  and  most  perceptible  to 
the  touch.  In  patients  whose  veins  are  but  slightly 
apparent,  or  in  whom  the  development  of  subcutaneous 
adipose  tissue  is  similar  to  that  of  a  woman,  the  veins 
can  be  felt  by  palpation. 

The  operator  then  takes  the  syringe  armed  with  the 
needle  in  his  right  hand,  holding  it  between  the  thumb 


INTRAVENOUS  INJECTIONS  657 

and  fingers,  the  little  finger  being  left  free  to  act  as  a 
support  on  the  patient's  arm.  He  traces  the  vein  with 
the  index  finger  of  the  left  hand  ;  then,  having  clearly 
determined  its  position  and  direction,  grasps  the 
patient's  arm  with  the  left  hand  in  the  following- 
manner  :  the  palm  and  four  last  fingers  are  applied 
to  the  posterior  surface,  while  the  thumb,  placed  on 
the  anterior  surface,  draws  down  the  skin  along  the 
selected  vein,  so  as  to  fix  it  and  prevent  its  slipping 
from  under  the  needle  (see  Fig.  2,  page  656). 

The  needle  is  held  with  its  bevel  turned  up  at  an 


Fig.  3. — ^The  needle  has  been  inserted  into  the  vein,  while  being 
held  parallel  to  the  skin.  Blood  has  flowed  into  the  body  of  the 
syringe.  New  position  of  the  fingers  of  right  hand  :  the  thumb 
holds  the  extremity  of  the  syringe  before  injecting  the  solution.  The 
left  thumb  has  not  been  moved, 

acute  angle  almost  parallel  to  the  surface  of  the  limb. 
The  operator  introduces  it  in  the  direction  of  the  vein, 
puncturing  the  skin,  then  pressing  forward  almost 
immediately  to  penetrate  the  vein  ;  in  this  second 
movement  it  is  necessary  to  further  reduce  the  angle 
of  the  needle  with  the  skin  and  direct  the  needle  almost 
parallel  with  it  (see  Fig.  3). 

The  penetration  of  the  needle  into  the  vein  is  signalled 
at  the  same  time  by  a  feeling  of  void  at  its  extremity, 
and  by  the  penetration  of  blood  into  the  body  of  the 
syringe.  Sometimes,  however,  blood  does  not  at 
once  flow  into  the  syringe,  although  one  is  convinced 


658  SYPHILIS   AND   THE   AEMY 

that  the  syringe  is  in  the  vein  ;  it  is  only  necessary 
to, make  slight  traction  on  the  piston  with  the  left  hand 
to  see  blood  flow  into  the  syringe. 

If  the  needle  has  not  penetrated  the  vein  at  the  first 
attempt,  it  should  be  withdrawn  gently  and  a  fresh 
attempt  made  to  introduce  it.  In  the  case  of  failure, 
make  a  fresh  puncture  of  the  skin  at  a  different  place, 
where  the  position  of  the  vein  appears  more  favourable. 
Care  must  be  taken,  however,  in  the  event  of  the 
puncture  of  the  skin  having  drawn  blood,  to  make 
the  fresh  attempt  on  the  other  arm. 

It  sometimes  happens  that  the  needle  is  blocked  by 
sl  small  clot  of  blood,  which  prevents  the  blood  from 
flowing  into  the  syringe  ;  therefore,  before  attempting 
to  make  a  fresh  injection,  it  is  well  to  convince  oneself 
of  the  permeability  of  the  needle,  by  pressing  the 
piston. 

When  the  operator  is  certain  that  the  needle  has 
penetrated  the  vein,  the  rubber  tourniquet  is  loosened. 
He  now  has  only  to  push  the  contents  of  the  syringe 
into  the  vein  ;  for  that  he  exercises  continuous  pressure 
on  the  piston,  either  by  means  of  the  right  thumb,  the 
syringe  being  held  in  position  between  the  index  and 
second  and  third  fingers,  the  little  finger  still  serving 
as  a  support  (see  Fig.  4,  page  fi59),  or  by  means  of  the 
left  hand. 

At  this  stage  it  is  necessary  to  be  certain  that  the 
fluid  is  flowing  into  the  vein,  and  has  not  been  intro- 
duced either  into  its  wall  or  into  the  perivenous 
cellular  tissue.  The  penetration  of  fluid  into  the 
tissues  causes  immediate  pain,  both  with  cyanide  of 
mercury  and  novarsenobenzol ;  directly  the  patient 
experiences  any  pain  other  than  the  very  slight  one 
of  piercing  the  skin — which  moreover  is  caused  at  the 
beginning  and  not  during  the  course  of  the  injection 
itself — the  operation  must  be  stopped  at  once,  an 
attempt  made  to  place  the  needle  more  correctly,  or, 
better  still,  recommence  the  injection  at  another  place. 


INTRAVENOUS  INJECTIONS 


659 


Another  indication  of  this  escape  of  fluid  is  the  pro- 
duction of  oedema  at  the  seat  of  puncture .  The  operator 
must  keep  his  eye  on  the.  operative  zone  during  the 
whole  course  of  the  injection  :  at  the  slightest  swelling 
of  this  region  he  must  suspend  all  pressure  of  the  piston. 

Any  abnormal  resistance  of  the  piston  to  the  thumb 
must  give  rise  to  fear  that  the  fluid  has  passed  into 
the  venous  wall.  When  this  is  felt  the  piston  must  be 
gently  withdrawn  ;  if  the  needle  is  in  a  good  position, 
blood  flows  into  the  syringe  ;  if  it  does  not,  the  needle 
must  be  immediately  withdrawn. 


Fig.  4. — The  tourniquet  has  been  removed.  The  right  thumb 
pushes  the  injection  into  the  ^•ein.  The  left  hand  supports  the 
forearm. 

If  a  little  air  has  got  into  the  syringe,  it  is  best  to 
stop  the  injection  before  the  piston  has  got  to  the 
end  of  its  course,  although  the  introduction  of  air 
into  the  veins  is  not  so  dangerous  as  was  formerly 
supposed. 

Once  the  injection  has  been  made,  it  is  well  to  draw 
back  the  piston  and  withdraw  a  few  drops  of  blood, 
to  relieve  the  extremity  of  the  needle  from  the  caustic 
fluid  which,  by  drying  on  the  venous  wall  or  in  the 
cellular  tissue,  might  cause  an  inflammatory  reaction. 

It  only  remains  to  withdraw  the  needle  and  put 
a  tampon  of  wool  soaked  in  alcohol,  or,  better,  in 
tincture  of  iodine,  on  the  puncture. 

After  the  injection  is  finished  the  patient  may  go 


660  SYPHILIS  AND  THE  ARMY 

back  to  his  work,  except  after  injections  of  novarseno- 
benzol,  when  he  must  rest  for  a  while. 

If  a  few  drops  of  blood  is^ue  from  the  little  wound, 
this  haemorrhage  can  be  easily  overcome  by  putting 
a  tampon  of  wool  on  the  puncture  and  telling  the 
patient  to  flex  his  elbow  strongly  for  some  minutes. 

After  the  injection,  the  syringe  must  always  be  care- 
fully washed  in  cold  water,  and  the  needle  must  be 
syringed  through  several  times  to  prevent  any  blood 
remaining  and  coagulating.  If  a  steel  needle  is  used, 
it  must  be  dried  by  air,  injected  with  vaseline  and 
greased  with  the  latter. 

Intravenous  injection,  despite  the  minute  technical- 
ities I  have  just  described,  is  nearly  always  a  simple 
and  easy  operation  which  can  be  performed  by  any 
oareful  and  fairly  skilful  surgeon.  After  a  few  days' 
practice  it  can  be  made  very  rapidly,  in  fact,  quite 
as  quickly  as  a  simple  subcutaneous  injection.  In 
my  hospital  clinic,  with  one  assistant  compressing  the 
arm,  and  another  cleaning  the  syringes  and  needles, 
and  having  them  boiled,  my  pupils  succeed  in  making 
sixty  injections  in  an  hour,  including  the  time  necessary 
for  charging  the  syringes.  I  have  even  seen  pupils 
make  as  many  as  thirty  injections,  without  accident, 
in  a  quarter  of  an  hour.  It  is,  therefore,  not  difficult 
in  a  venereological  section  on  active  service  to  treat 
the  majority  of  patients  by  this  process,  on  condition 
that  the  assistants  are  intelligent,  careful,  and  well 
trained. 

It  must  be  recognised,  however,  that  with  certain 
subjects  an  intravenous  injection  presents  certain 
difficulties.  This  is  rarely  the  case  with  vigorous 
adult  men,  with  whom  alone  we  have  to  deal  here. 
Sometimes,  however,  the  veins  at  the  bend  of  the  elbow 
are  small,  buried  in  adipose  subcutaneous  tissue, 
and  difficult  to  find,  even  on  palpation.  If  none  can 
be  felt  in  this  region,  the  injection  must  be  made  in 
the  forearm   where  it  is  rare  not  to  find  a  sufficientl3 


J 


INTRAVENOUS   INJECTIONS  661 

large  vein  on  the  outer  side  ;  the  position  the  patient 
is  obliged  to  assume  to  present  it  to  the  operator  is 
uncomfortable  for  both,  but  the  injection  is  possible. 
It  is  only  as  a  last  resource  that  an  injection  should  be 
made  in  a  vein  of  the  lower  limbs,  because,  owing  to 
the  frequency  of  varicose  veins,  infection  is  easier  and 
more  serious  than  in  the  upper  limbs. 

One  difficulty  may  arise,  not  from  the  smallness, 
but  from  the  mobility  of  the  veins,  which  sometimes 
causes  inconvenience  to  beginners  :  the  vein  slips 
away  and  cannot  be  perforated  by  the  needle.  To 
prevent  this,  the  best  method  consists  in  holding  the 
vein  in  position  by  means  of  the  left  thumb,  in  the 
way  I  have  recommended  above.  It  has  also  been 
proposed  that,  instead  of  piercing  the  vein  in  its 
prominent  part,  it  should  be  approached  laterally,  by 
introducing  the  needle  into  the  skin  a  little  outside 
the  vessel,  and  then  pushing  it  slowly  towards  the 
vein  ;  the  limit  of  its  elasticity  is  soon  reached,  it 
ceases  to  escape  from  the  point,  and  can  be  perforated 
by  the  needle  ;  when  penetrated,  the  vein  becomes 
distended  and  resumes  its  normal  position. 

Operative  Accidents 

The  only  operative  accidents  which  may  result  from 
an  intravenous  injection  are  the  introduction  of  the 
injected  fluid  into  the  venous  wall,  and  its  penetration 
into  the  perivenous  cellular  tissue. 

Intraparietal  penetration  may  occur  when  the 
orifice  of  the  needle  is  too  elongated.  It  may  happen 
that  the  orifice  is  partly  in  the  internal  tunica  of  the 
vein  and  partly  communicates  with  the  lumen  ;  when 
the  operator  aspirates  the  syringe,  blood  flows  into 
it, -and  the  operator  consequently  believes  that  he 
is  in  the  lumen  of  the  vein,  but  the  remainder  of  the 
orince  of  the  needle  draws  the  injection  fluid  into  the 
vascular   wall   itself.     This   causes   immediate   pain, 


662  SYPHILIS   AND   THE   ARMY 

followed  by  an  inflammatory  reaction  with  painful 
induration  which  persists  for  several  weeks,  and  may 
hinder  the  continuation  of  treatment. 

The  penetration  of  the  fluid  into  the  perivenous 
cellular  tissue  may  occur  either  from  the  side  or  front 
of  the  vein,  or  behind,  when  the  needle  has  been 
introduced  roughly  or  at  too  wide  an  angle,  and  has 
passed  through  the  vein  from  one  side  to  the  other. 
This  penetration,  as  I  have  already  stated,  may  be 
avoided  or  arrested  at  once,  if  care  is  taken  to  watch 
closely  the  injection  zone,  and  the  patient  is  advised 
to  at  once  report  any  unusual  pain.  With  cyanide 
of  mercury  and  novarsenobenzol,  which  are  very 
irritating  substances,  there  is  acute  pain,  the  production 
of  a  more  or  less  extensive  inflammatory  nodule,  and 
often  an  eschar  which  may  attain  the  dimension  of  a 
shilling,  become  detached  slowly,  leave  a  loss  of  sub- 
stance, and  ultimately  an  adherent  cicatrix. 

When  this  accident  is  observed,  the  intensity  of 
inflammation  and  subsequent  dimensions  of  the 
eschar  may  be  notably  reduced  by  immediately  per- 
forming massage  of  the  region,  so  as  to  cause  reflux 
of  the  greatest  possible  quantity  of  noxious  fluid 
by  the  track  of  the  needle.  Further,  compresses 
soaked  in  fresh  water  should  be  applied  at  once  and 
renewed  frequently. 

It  is  not  rare,  even  after  an  injection  which  has  been 
properly  performed,  for  a  subcutaneous  ecchymosis  to 
appear,  due  to  infiltration  of  blood  from  the  passage 
of  the  needle  into  the  cellular  tissue  :  this  is  an  incident 
of  no  importance. 

Some  patients  complain  of  acute  pain  the  moment 
the  skin  is  pierced,  which  persists  for  some  minutes 
extending  down  the  forearm.  This  occurs  when  a 
nerve  filament  has  been  injured  by  the  needle,  but 
this  pain  never  lasts  long. 

Finally,  with  the  excej^tion  of  eschars,  which  may 
be  avoided  almost  entirely,  given  careful  technique, 


INTRAVENOUS  INJECTIONS  663 

there  are  never  any  accidents  of  importance  caused 
as  the  result  of  intravenous  injections.  I  do  not 
know  of  a  single  case  of  subsequent  embolism,  even  if 
venous  indurations  have  developed. 


Precautions  to  be  taken  after  Intravenous  Injections  of 
Cyanide  of  Mercury 

Mercury,  injected  into  the  veins  in  the  form  of 
cyanide,  is  absorbed  very  rapidly,  much  more  so  than 
with  any  other  form  of  mercurialisation.  This  is  one 
of  the  advantages  of  the  method,  but  it  may  i'esult  in 
the  possibility  of  an  accident,  which  must  be  recognised 
and  warned  against — mercurial  colitis. 

Certain  subjects,  the  majority  having  previously 
suifered  from  digestive  disorders,  some  hours,  or 
perhaps  even  within  an  hour,  of  the  intravenous  in- 
jection of  cyanide  of  mercury,  are  suddenly  seized 
with  acute  pain  in  the  region  of  the  colon,  violent 
rectal  tenesmus,  more  or  less  copious  diarrhoea,  with 
first  sanguinolent,  than  ha^morrhagie  stools.  These 
symptoms  may  last  one,  two,  or  three  days,  and,  owing 
to  the  loss  of  blood,  cause  pronounced  anaemia.  Treat- 
ment consists  in  the  internal  use  of  opium  in  adequate 
doses,  the  administration  of  emollient  enemas,  and 
application  on  the  abdomen  of  wool  soaked  in  laudanum 
or  large  linseed  poultices  with  laudanum. 

These  accidents  may  be  prevented  almost  certainly 
if,  at  the  time  of  injection,  the  patient  is  given  an 
opium  pill  of  two  or  five  centigrammes,  as  I  have  made 
a  rule  of  doing  in  my  hospital  clinic. 

It  may  be  mentioned  that  these  accidents  are 
produced  almost  exclusively  after  the  first  or  second 
injection  of  cyanide.  With  subjects  who  seem  pre- 
disposed to  intestinal  troubles  and  with  elderly  or 
exhausted  patients,  I  have,  therefore,  made  it  a  rule 
to  give  the  first  injection  of  cyanide  in  a  dose  of  half 


664  SYPHILIS  AND   THE  ARMY 

a  centigramme,  or  even  of   a  quarter,  and  increase 
this^  gradually. 

When  the  patient  has  had  an  attack  of  colitis  after 
the  first  injection  of  cyanide,  treatment  may  be  resumed 
with  this  method  later,  after  waiting  a  few  days  and 
recommencing  with  small  doses  of  cyanide. 

Injections  of  cyanide  of  mercury  must  also  be  used 
With  circumspection  in  the  case  of  albuminuric  patients. 
Some  patients  have  a  recrudescence  of  their  albumi- 
nuria after  the  injections,  resulting  from  the  irritative 
action  of  mercury  on  the  kidneys.  Treatment  must 
not  be  continued  with  these  patients.  With  others, 
no  disturbing  effects  at  all  are  noticed,  but  both  urine 
and  diet  must  be  under  constant  supervision. 

As  with  all  mercurial  treatment,  the  teeth  and  gums 
must  be  examined  before  giving  cyanide  of  mercury 
injections,  and  kept  under  observation  during  treat- 
ment. However,  owing  to  the  rapid  elimination  of 
the  drug,  stomatitis  is  rare  in  patients  treated  by  this 
method. 

All  the  same,  if  only  by  way  of  precaution  and  to 
accustom  the  patients  to  take  the  necessary  care  of 
their  mouth  and  teeth  during  mercurial  treatment, 
they  must  be  ordered  to  wash  out  the  mouth  twice 
daily  with  white  soap  or  with  a  tooth-powder  contain- 
ing a  sufficient  proportion  of  soap. 

Precautions  to  be  taken  after  Intravenous  Injections  of 

Novarsenobenzol 

As  I  have  shown  above,  the  after-effects  of  arseno- 
benzol  injections  are  generally  mild.  Especially  with 
the  method  of  concentrated  injections,  these  are 
nearly  always  reduced,  when  they  do  occur,  to  tran- 
sient rise  of  temperature,  of  which  the  patient  has 
sometimes  no  knowledge. 

But,  in  order  to  obtain  this  result,  it  is  necessary 
that  the  patient  should  have  only  had  light  food,  not 


INTRAVENOUS  INJECTIONS  665 

less  than  three  hours  before  the  injection,  and  that, 
afterwards,  he  should  keep  quiet  and  be  dieted. 

For  hospital  patients,  rest  in  bed  immediately  after 
the  injection,  and  for  the  whole  day,  is  the  rule. 

When  patients  only  come  into  hospital  for  the 
injection,  they  can  return  home  at  once  on  foot,  if 
they  live  near,  otherwise  drive,  and  go  to  bed  for 
the  day.  They  can  resume  their  ordinary  work  the 
following  day. 

During  the  day  following  the  injection,  they  must 
be  kept  on  a  strict  diet ;  water  and  liquids  are  alone 
permitted ;  at  most  they  may  be  allowed  some  soup 
or  an  egg  five  hours  at  least  after  the  injection. 

I  have  seen  patients  seized  with  rigors,  intense  fever, 
profuse  sweating,  and  repeated  vomiting,  after  having 
disobeyed  these  orders  and'^taken^even  a  light  meal. 


CHAPTER   VII 

HYGIENE    OF    SYPHILITIC    SOLDIERS 

Hygienic  measures,  although  often  neglected,  are  of 
the  utmost  importance  in  syphilis. 

A  considerable  number  of  these  measures  are  super- 
fluous, or  impracticable,  in  the  case  of  soldiers.  There 
is  no  need,  in  the  Army,  to  recommend  rest,  fresh  air. 
moderate  exercise  and  no  late  hours,  such  as  are 
prescribed  for  civilians. 

Useful  advice,  which  can  be  put  into  practice  when 
the  men  are  in  camp  or  at  the  base,  is  to  keep  the 
body  clean,  especially  the  genital  organs,  by  means 
of  washing,  baths,  or  douches  ;  these  are  precautions 
all  soldiers  should  take  whenever  they  have  the 
opportunity. 

The  following  advice  is  specially  suitable  for  syphi-^ 
litics. 

(1)  Suppression  of  Tobacco. — This  should  be  pro- 
scribed for  all  syphilitics,  at  any  rate  during  the  first 
year  of  the  disease.  Tobacco,  no  matter  under  what 
form,  pipe,  cigarette,  cigar,  or  quid,  is  the  principal 
exciting  cause  of  buccal  mucous  plaques.  A  syphilitic, 
who  is  well  treated,  and  neither  smokes  nor  chews, 
is  almost  certain  to  escape  them.  In  hospital,  the 
doctor  must  insist  upon  total  abstinence  from  tobacco 
for  all  syphilitics. 

When  the  -man  has  returned  to  his  unit  he  often 
ignores  this  prescription  ;  it  is  the  duty  of  the  medical 
man  to  remind  him  of  it.     When  a  patient  has  had 

666 


HYGIENE   OF   SYPHILITIC   SOLDIERS     667 

numerous  recurrences  of  buccal  mucous  plaques,  and 
continues  to  smoke  despite  repeated  orders  to  the  con- 
trary, he  should  be  threatened  with  military  punish- 
ment. 

(2)  Hygiene  of  the  Mouth. — After  the  use  of  mercury, 
stomatitis  often  develops  in  patients  whose  buccal 
mucous  membrane  is  not  in  good  condition,  especially 
in  the  region  of  the  gums  and  teeth.  It  is  indispensable 
that  all  syphilitics  should  take  particular  care  of  the 
mouth. 

The  patient's  teeth  must  be  examined  before  treat- 
ment is  commenced,  and,  if  necessary,  they  must  be 
cleaned  by  a  dentist,  and  all  bad  teeth  stopped.  During 
mercurial  treatment  this  examination  should  be 
repeated. 

Further,  every  day  during  mercurial  treatment,  the 
teeth  and  gums  should  be  cleansed  twice  or  even  thrice 
with  a  brush,  soap  and  water,  or  with  a  powder  con- 
taining soap. 

Salol,  frequently  recommended  for  cleansing  the 
mouth,  has  an  irritant  action  on  the  skin,  and  often 
causes  eczema  of  the  labial  commissures  ;  any  prepara- 
tions containing  it  should  be  severely  avoided. 

Many  medical  men  prescribe  mouth  washes  of 
chlorate  of  potash  for  their  syphilitic  patients.  This 
.solution  has  merely  a  detergent  action  and  has  no 
advantage  over  simple  boiled  water.  As  a  prophy- 
lactic measure  against  mercurial  stomatitis,  it  is  far 
inferior  to  a  soap-wash.  Hence,  I  see  no  reason  for 
recommending  it. 

(3)  Drinks. — Syphilitics  must  avoid  the  abuse  of 
alcohol,  take  wine  moderately,  and  refrain  from  all 
liqueurs  and  spirits. 

(4)  Clothing. — Mercury  easily  induces  diarrhoea; 
syphilitic  patients  should,  therefore,  avoid  getting 
cold  in  the  abdomen,  and  a  flannel  cummerbund  is 
recommended. 

( 5 )  Sexual  Relations . — Syphilitics  should  refrain  from 


668  SYPHILIS  AND   THE  ARMY 

sexual  intercourse  during  the  first  months,  even  where 
no  contagious  lesion  is  to  be  found  on  the  genital 
organs.  As  a  matter  of  fact,  the  blood  is  contagious 
at  this  period,  and  there  is  always  risk  of  an  excoriation 
being  produced  during  the  sexual  act. 

The  patient  must  be  advised  as  to  the  dangers  of 
contagion,  of  the  lengthy  period  during  which  it  may 
exercise  its  influence,  and  of  the  necessity  for  consulting 
a  medical  man  before  marriage,  or,  in  the  case  of 
married  men,  of  resuming  marital  relations. 


CHAPTER   VIII 

PROPHYLAXIS 

The  prophylaxis  of  syphilis  concerns  not  only  the 
military,  but  also  the  civil  population,  more  than  any 
other  contagious  disease  which  may  attack  the  Army, 
owing  to  its  conditions  of  transmission  It  constitutes 
a  social  danger,  against  which  every  competent  and 
authorised  effort  should  be  directed,  for  it  can  only 
be  combated  by  measures  carried  out  by  the  combined 
action  of  the  military  and  civil  authorities. 

These  measures,  of  unequal  importance  and  variable 
scope,  should  be  carried  out  with  vigilance,  energy, 
and  perseverance  if  satisfactory  results  are  to  be 
obtained.  They  concern  men  who  are  infected  with 
syphilis,  men  who  are  not  infected,  and  women  who 
may  contract  and  transmit  the  disease.  They  may 
be  classified  in  two  main  groups  : 

1 .  Measures  intended  to  prevent  infected  men  from 
transmitting  syphilis  ; 

2.  Measures  intended  to  prevent  healthy  men  from 
contracting  syphilis. 

NECESSARY  PRECAUTIONS  FOR  PREVENTING  THE 
TRANSMISSION  OF   SYPHILIS  BY  INFECTED  MEN 

These  measures  are  all  within  the.  province  of  tho 
military  authorities  ;  they  are  given  in  simple  rules 
or  circulars  emanating  from  headquarters,  and  can 
be  easily  applied. 

The  majority  of  these  measures  were  already  in 

669 


670  SYPHILIS   AND   THE   ARMY 

force  in  peace  time ;  the  increased  frequency  of 
syphilis  as  the  result  of  the  war  renders  their  execution 
much  more  urgent  :  the  circulars  of  the  Under- 
Secretary  of  State  of  the  Army  Medical  Service,  dated 
January  5th  and  September  25th,  1916,  set  these  out 
officially. 

The  carrying  out  of  these  measures  really  depends 
less  on  the  officer  in  command  than  upon  the  doctor, 
whose  duty  it  is  to  see  that  they  are  performed  in  each 
particular  case. 

Isolation  of  Syphilitic  Carriers  of  Contagious  Lesions 

Syphilis  is  transmitted  exclusively  by  direct  contact 
of  the  secretion  product  from  one  of  the  lesions.  Thus, 
it  can  only  be  transmitted  by  open  syphilitic  lesions, 
and  then  only  during  the  early  stages ;  later  ulcerative 
lesions  are  only  exceptionally  contagious.* 

On  the  other  hand,  these  open  lesions  become  cica- 
trised, either  spontaneously,  or  under  the  influence 
of  treatment  in  a  relatively  short  time.  As  regards 
treatment,  I  have  shown  that  the  cicatrisation  of  a 
chancre,  or  of  mucous  plaques,  subjected  to  energetic 
medication  at  once  is  a  question  of  fifteen  to  twenty 
days  at  the  utmost. 

Therefore,  to  prevent  a  syphilitic  patient  from  doing 
any  harm,  it  is  necessary,  and  in  all  probability  suffi- 
cient, to  isolate  him  during  fifteen  to  twenty  days, 
both  in  the  case  of  infective  chancre,  and  mucous 
plaques  of  the  genital  organs,  anus,  mouth,  or  pharynx. 

As  a  rule,  these  symptoms  attract  the  attention  of 
the  patient  sufficiently  to  induce  him  to  consult  the 
doctor. 

All  the  same,  it  is  imperative  that  all  syphilitic 
patients  should  be  examined  by  the  medical  officers 
of  their  company  :    many  pay  little   attention  to   a 

*  Transmission  by  blood  does  exist,  but  it  is  so  rare  that  it  need 
not  be  taken  into  account  in  prophylactic  practice. 


PROPHYLAXIS  671 

small,  painless  sore,  causing  no  inconvenience,  of 
which  they  suspect  neither  the  nature  nor  danger, 
especially  if  it  be  a  dwarf  chancre  or  single  mucous 
plaque.  Some  are  afraid  of  being  sent  to  hospital,  or 
deprived  of  leave,  if  they  complain  of  a  lesion  of  the 
genital  organs,  while  others,  again,  dread  treatment  or 
fear  to  divulge  their  malady. 

In  short,  despite  the  recommendations  and  good 
intentions  of  the  medical  officers,  many  syphilitics 
escape  examination  and  remain  in  the  regiments, 
unless  the  doctors  have  permission  to  search  for  them 
and  succeed  in  running  them  to  earth. 

Medical  Inspection 

Even  in  times  of  peace,  regimental  orders  provide 
for  the  medical  inspection  of  the  men,  especially  as 
regards  venereal  disease,  at  the  time  of  enlisting,  and 
when  going  on  leave  and  returning. 

These  visits  include  examination  of  the  genital 
organs,  anus,  and  buccal  cavity.  In  order  to  be 
really  efficacious  in  the  discovery  of  the  great  majority, 
if  not  of  the  total  number,  of  syphilitics,  the  medical 
man  must  bring  to  bear  on  the  case  careful  attention, 
and  genuine  knowledge  of  syphilitic  disturbances  of 
the  skin  and  mucous  membranes. 

Two  conditions  are  demanded,  which  are  not  always 
forthcoming  : 

(1)  Sufficient  time  for  the  examination  of  each  man, 
which  is  not  possible  in  many  circumstances,  especially 
at  the  departure  for,  and  return  from,  leave. 

(2)  Proper  lighting  arrangements  and  instruments 
necessary  for  the  effective  ^examination  of  the  patients. 
These  requirements  are  far  from  being  satisfactorily 
fulfilled  in  a  hut  or  tent  where  the  light  is  often  bad. 
As  to  instruments,  these  are  nearly  always  rudimentary, 
and  the  doctor  has  to  make  the  most  strenuous  efforts 
to  see  the  different  parts  of  the  buccal  cavity. 


672  SYPHILIS  AND  THE  ARMY 

It  is  hardly  necessary  to  mention  that  all  men 
should  be  compelled  to  attend  the  visit  of  inspection. 
Control  by  the  commanding  officer  and  supervision 
by  the  non-commissioned  officers  are  indispensable, 
when  certain  men  who,  knowing  they  are  syphilitic, 
try  all  they  can  to  evade  detection. 

The  order  which,  in  time  of  peace,  releases  non- 
commissioned officers  from  medical  inspection,  does 
not  hold  good  during  war,  and  should  be  abolished. 
It  is  necessary  owing  to  the  conditions  of  common 
life  in  camp,  the  fact  of  N.C.O.'s  being  often  younger 
than  their  men,  and  especially  on  account  of  the  great 
frequency  of  syphilis. 

It  seems  difficult,  but  should  be  legitimate  never- 
theless, to  compel  officers  to  submit  to  medical  inspec- 
tion :  it  is  due  to  medical  men  attached  to  the  Army 
to  use  their  influence  with  officers,  and  persuade  them 
to  consult  them  on  the  slightest  suspicious  manifesta- 
tion. 

The  ministerial  circular  of  April  7th,  1912,  advises 
monthly  medical  visits  of  inspection.  This  periodicity 
is  inadequate.  The  circular  issued  on  September  25th, 
1916,  was  right  in  advising  that  they  should  be  made 
twice  a  month.  To  be  really  efficacious  the  visit  should 
be  a  surprise  one. 

Regulations  order  the  medical  inspection  of  all  men 
starting  on  leave  and  forbid  that  any  soldier  carrying 
contagious  symptoms  should  be  allowed  to  go,  and 
another  inspection  when  the  men  return  from  furlough. 
I  doubt  whether  this  second  order,  which  is  quite 
rational,  is  often  put  into  practice. 

The  visits  are  made  in  the  companies  of  the  regiment, 
the  depots,  and  the  majority  of  the  services  in  a  more 
or  less  regular  manner,  and  too  much  pressure  cannot 
be  brought  to  bear  on  the  doctors  as  to  their  importance. 
In  any  case,  it  is  imperative  that  they  should  also  be 
made  in  munition  works  and  on  all  mobilised  workmen, 
whether  French  or  belonging  to  Colonial  contingents, 


PROPHYLAXIS  673 

who  are  working  there.  These  men  are  under  military 
control,  but  have  more  opportunities  and  facilities 
than  soldiers  at  the  front  for  contracting  and  dis- 
seminatiDg  syphilis,  and  do  not  neglect  them  ;  more- 
over, they  are  very  often  infected,  and  in  a  higher 
proportion  than  occurs  in  soldiers  at  the  front.  They 
should,  therefore,  be  compelled  to  submit  to  medical 
inspection,  which  should  be  as  rigorous  as  that  of  the 
latter.  It  would  be  easy  for  some  arrangement  to 
be  made  between  the  medical  men  and  managers  of 
munition  works,  in  order  that  the  inspection  could 
be  made  at  an  hour  when  it  would  not  interfere  with 
work. 

Similarly,  in  the  medical  centres  inspection  should  be 
made  of  men  who,  while  under  treatment,  are  given 
leave  to  go  out,  even  if  only  for  a  few  hours.  In  small 
localities,  as  in  large  towns,  a  great  number  of  them 
contract  sjrphilis.  The  majority,  whose  manifestations 
are  very  evident,  cannot  dissimulate  their  condition 
to  the  doctor  in  charge,  who  takes  the  necessary 
precautions  ;  but  a  certain  number  of  them  escape 
medical  control  and  treatment.  Very  justly,  the 
circular  of  September  25th,  1916,  prescribes  that  all 
wounded  under  treatment  at  the  different  centres 
should  be  subjected  to  bi-monthly  inspection,  and,  in 
case  of  venereal  infection,  treated  whenever  possible 
like  the  men  in  the  depots.  I  have  reason  to  believe 
that  this  inspection  is  often  neglected ;.  it  would  be 
invaluable  in  places  where  the  wounded  are  kept  long, 
but  have  frequent  leave,  particularly  in  physio-thera- 
peutic, mechano-therapeutic,  and  neurological  centres. 

Syphilitics  and  Hospital  Treatment 

Every  syphilitic  patient,  who  is  a  recognised  carrier 
of  one  or  more  contagious  manifestations,  should  he  sent 
to  hospital,  at  any  rate  untU  these  symptoms  disappear. 
This  is  the  absolute  rule  laid  down  in  the  circvdar  of 


674  SYPHILIS  AND  THE  ARMY 

September  25th,  1916,  which  orders  that  any  patients 
suffering  from  chancre  or  the  slightest  suspicious  erosion 
must  be  sent  to  a  venereal  hospital.  No  exception 
can  be  allowed,  at  any  rate  as  concerns  soldiers  and 
non-commissioned  officers,  no  matter  what  their 
position  or  employment. 

The  same  rule  should  be  established  for  officers,  but 
it  might  be  difficult  to  get  it  accepted  :  it  is  due  to  the 
medical  officer  to  decide  in  each  particular  case  what 
is  best  to  be  done,  having  regard  to  the  usefulness  of 
the  officer  in  his  position,  and  the  precautions  he  is 
able  to  take  against  disseminating  the  disease.  If 
hospital  treatment  is  necessary,  the  medical  officer 
should  assert  his  authority,  in  order  to  get  this  effected  ; 
otherwise,  he  must  carry  out  energetic  treatment  him- 
self. 

The  hospital  should  be  made  an  absolute  rule  for 
all  men  mobilised  in  munition  works,  because  they 
are  the  most  dangerous  to  the  civil  population  in  which 
they  live.  Some  doctors,  in  charge  of  the  medical 
inspection  of  munition  works,  when  consulted  by  a 
workman  with  chancre,  give  him  a  fortnight's  rest, 
so  that  he  may  be  treated.  This  practice  is  deplorable. 
In  the  majority  of  cases,  the  workman  waits  some 
days  before  going  to  a  hospital,  receives  a  prescription, 
which  is  often  inadequate,  uses  it  badly,  and  when  the 
fortnight  is  over,  during  which  he  has  rarely  failed  to 
contaminate  some  woman,  his  chancre  has  not  healed. 
Every  time  a  mobilised  workman  has  consulted  me 
I  have  refused  to  give  him  a  prescription  and  am- 
bulatory treatment,  and  have  sent  him  to  the  doctor 
of  his  works  with  a  note  indicating  the  necessity  for 
his  being  sent  to  hospital,  and  I  must  acknowledge 
that  he  has  always  sent  the  patient  back  to  me  with 
this  object. 

Similarly  when,  from  physio-therapeutical  or  neuro- 
logical centres,  a  wounded  soldier  under  treatment  has 
been  sent  to  me  with  a  syphilitic  chancre  or  mucous 


PROPHYLAXIS  675 

plaque,  the  medical  man  in  charge  arranges  to  send 
him  to  me  every  day,  if  necessary,  for  an  injection. 

Sending  a  patient  to  hospital  implies  really  that  he 
will  get  active  syphilitic  treatment  in  order  to  reduce 
internment  to  a  minimum.  I  have  insisted  upon  this 
sufficiently  when  describing  the  treatment  of  syphilis 
and  need  not  revert  to  it.  The  mere  fact  of  being 
in  hospital,  in  the  majority  of  cases,  allows  energetic 
anti-syphilitic  therapy.  The  Under-Secretary  of  State 
has  insisted  upon  this  very  rightly  since  January  5th, 
1916. 

In  the  case  of  contagious  syphilis,  the  patient,  when 
in  hospital,  must  be  isolated ;  that  is  to  say,  during 
his  whole  sojourn  he  must  not  be  allowed  to  go  out, 
on  any  pretext  whatever.  That  is  evident.  In 
exceptional  cases,  permission  may  be  given  to  patients 
to  go  out,  if  their  time  in  hospital  has  been  prolonged 
by  more  or  less  grave  general  symptoms,  or  intercurrent 
diseases;  but  only  on  the  strict  condition  that  there 
are  no  longer  any  active  contagious  lesions.* 

On  leaving  hospital,  there  is  no  reason  for  sending 
syphilitic  patients  on  furlough,  as  is  usually  the  case 
with  wounded  and  sick  soldiers  evacuated  from  the 
Front.  There  is  no  medical  reason  why  they  should 
not  at  once  go  back  to  duty  ;  their  general  condition 
is  seldom  changed  by  the  disease,  and  even  intensive 
arsenical  medication  improves  nutrition  so  much  that 
syphilitics  are  often  in  a  better  condition  of  health 
when  leaving  hospital  than  they  were  on  admission. 

On  the  other  hand  also,  the  concession  of  leave 
when  discharged  from  hospital  would  constitute  a 
sort  of  premium  on  the  reproduction  of  syphilitic 
symptoms,  and,  if  syphilitics  are  not  to  be  punished 

*  As  refusal  of  leave  is  ixot  intended  as  a  disciplinary  measure,  the 
remnants  of  the  old-fashioned  ideas  with  regard  to  "  secret "  or 
"  shameful"  diseases,  but  merely  as  a  hygienic  precaution,  it  is  not 
well  to  refuse  permission  to  syphilitics  suffering  from  tertiary 
lesions,  whether  ulcerous  or  not,  as  there  need  be  no  fear  of  their 
spreading  contagion. 


676  SYPHILIS  AND   THE  ARMY 

for  having  contracted  the  disease,  it  would  be  a  pity 
for  them  to  obtain  a  benefit  from  it,  in  the  form  of 
leave. 

There  is  justice,  therefore,  in  the  circulars  of  January 
5th  and  September  25th,  1916,  having  ordained  that, 
on  principle,  neither  leave  nor  convalescence  should 
be  granted  to  venereal  patients  when  discharged  from 
hospital. 

Locality  of  Hospitalisation  for  Syphilitics. — As  a 
general  rule,  they  should  be  sent  into  hospital  as  near 
their  military  post  as  possible. 

A  syphilitic  soldier  should  never  be  evacuated  from 
the  Front  to  the  interior,  except  in  the  case  of  serious 
complications.  It  is  important  to  keep  him  close  to 
his  regiment,  so  that,  directly  the  treatment  is  finished, 
lie  can  rejoin  ;  instructions  are  positive  on  this  point, 
^nd  there  is  no  necessity  to  justify  them. 

Even  in  the  interior,  the  patient  should  be  kept  as 
near  his  centre  or  depot  as  possible. 

But,  along  with  this  rule,  another  element  must  be 
taken  into  consideration  :  the  necessity  of  seeing  that 
the  patient  is  given  thorough  treatment,  i.e.  he  should 
be  placed  in  a  medical  centre  supplied  with  all  requisite 
resources,  not  only  in  material  installations,  but  also 
as  regards  a  competent  medical  staff. 

No  matter  what  one  may  think,  the  diagnosis  and 
treatment  of  syphilis  necessitate  an  adaptation  of 
material  and  staff  in  order  to  be  carried  out  with  a 
minimum  of  expense,  time,  and  risk. 

The  creation  of  venereological  centres,  or  dermato- 
syphiligraphic  centres,  has  been  realised  very  happily, 
in  the  army  zone,  as  well  as  in  the  interior. 

There  is  no  doubt  that  expert  medical  men,  under- 
standing syphilis  and  its  treatment,  may  be  found  in 
all  the  centres,  and  I  am  acquainted  with  a  fair  number 
of  doctors  attached  to  regiments,  ambulances,  and 
temporary  hospitals,  who  are  capable  of  guaranteeing 
the  treatment  and  recovery  of  their  syphilitic  patients 


PROPHYLAXIS  677 

under  the  best  conditions,  and  in  whom  one  may  have 
confidence.  In  certain  cases,  there  may  be  an  advant- 
age in  not  removing  the' patient  from  his  unit  and 
centre,  but  this  is  applicable  only  in  particular  cases. 
The  general  rule,  to  which  one  must  bow  in  the  majority 
of  cases,  is  to  send  syphilitic  patients  to  hospital,  or 
to  a  centre  specialised  for  the  treatment  of  syphilis  : 
in  the  army  zone,  to  a  hospital  placed  in  an  important 
medical  centre  ;  in  the  interior,  to  a  special  hospital 
clinic,  or  dermato-syphiligraphic  centre  of  the  region. 
The  number  of  these  clinics  and  centres  cannot  and 
should  not  be  very  considerable  ;  it  must  vary  accord- 
ing to  the  regions,  and  may  even  vary  at  different 
periods,  increasing  if  the  number  of  syphilitics  suddenly 
becomes  visibly  augmented.  They  should  be  situated 
in  the  neighbourhood  of  large  military  and  hospital 
agglomerations,  so  as  to  reduce  simultaneously  the 
number  and  length  of  movements  of  the  patients. 
Their  position,  however,  has  been  judiciously  settled 
by  the  military  authorities,  who-  have  created  sub- 
centres  of  varying  number,  where  they  appeared  to 
be  necessary. 

Beyond  the  fact  that  the  creation  of  centres  and 
special  services  permits  of  the  utilisation  of  competent 
medical  men,  reduces  the  number  of  similar  installa- 
tions and,  consequently,  enables  them  to  be  endowed 
with  the   material  necessary  for  the   diagnosis  and 
treatment  of  syphilis,  these  clinics  and  centres  have 
the  advantage  of  grouping  together  syphilitic  patients. 
They    facilitate    supervision,    which    must    be    more 
active  than  for  ordinary  patients^  on  account  of  the 
contagiousness  of  the  disease,  as  well  as  the  suppression 
of  leave  and  interdiction  of  tobacco      In  all  respects, 
they  give  a  far  superior   curative  and   prophylactic 
result  than  that  obtained  when  syphilitic  patients  are 
placed  in  an  ordinary  hospital.     I   may  add  that, 
owing  to  their  position  near  the  principal  places  of 
the  region,  the  venereological  centres  are  able  more 


678  SYPHILIS  AND   THE  ARMY 

rapidly  and  completely  to  enlighten  the  medical 
officer  of  health  and  the  commanding  officer  as  to  the 
variations  of  syphilis,  the  foci  of  contagion,  and 
precautions  to  be  taken  in  conjunction  with  the  civil 
authorities  for  arresting  their  progress. 

Advice  to  be  given  to  Syphilitic  Patients  in  Hospital. — 
The  time  in  hospital  must  serve,  not  only  for  treating 
the  patient,  but  also  for  educating  him  with  regard 
to  his  disease  and  its  after-effects,  on  the  precautions 
he  must  take  while  in  the  Army  and  on  his  return  to 
civil  life. 

The  discussions  held  with  the  men  on  venereal 
diseases  from  the  moment  of  their  admission  to  the 
Army  are  intended  to  teach  them  how  to  avoid  venereal 
diseases  and  learn  what  to  do  when  suffering  from 
them ;  but  they  are  often  f6rgotten  when  the  man  ha& 
become  syphilitic.  It  is  necessary  now  to  complete 
and  develop  these,  no  longer  by  ex  cathedra  addresses, 
but  by  personal  conversations  with  the  men  :  in  a  few 
words,  the  doctor  must  make  the  patient  realise  the 
real  gravity  of  his  disease  and  the  precautions  he 
should  take,  rectifying  false  or  incomplete  ideas, 
frightening  men  who  are  too  indifferent,  and  reassuring 
those  who  have  got  an  exaggerated  idea  of  the  gravity 
of  syphilis  and  its  after-effects.  The  niedical  man 
in  attendance  is  thus  endowed  with  a  duty  of  the 
highest  importance,  both  from  a  humanitarian  and 
social  point  of  view,  which  belongs  to  him  alone,  and 
in  which  he  can  give  full  play  to  his  concern  for  the 
welfare  of  his  patients  and  of  the  public. 

In  order  to  facilitate  this  individual  instruction,  and 
at  the  same  time  impress  it  upon  the  patient's  memory, 
the  majority  of  sy philologists  have  for  a  long  time 
written  and  distributed  among  their  patients  a  short 
pamphlet,  giving  the  general  rules  for  the  treatment 
of  syphilis,  and  the  precautions  to  be  taken  to  avoid 
transmission.  The  circular  of  September  25th,  1916, 
advises    that    these    pamphlets    should    be    given    to 


PROPHYLAXIS  cry 

syphilitics  leaving  special  centres,  and  discussed  with 
them.  They  are  printed  on  a  sheet  of  strong  paper 
and  can  be  kept  in  the  pocket-book  as  a  guide  for 
patients.  It  is  my  custom  to  give  one  to  the  patient 
when  I  examine  him  for  the  first  or  second  time ;  I 
ask  him  to  read  it,  and,  at  a  subsequent  examination, 
it  is  discussed  and  explained  to  him  either  by  me  or 
by  one  of  my  students. 

It  is  useful,  when  discharging  the  patient,  to  give 
him  a  written  statement  indicating  the  symptoms  from 
Avhich  he  has  been  suffering,  the  treatment  he  has 
received  (drugs  used  and  doses),  and  the  dates  of  ad- 
mission and  discharge.  These  data  may  be  put  on  a 
simple  sheet  of  strong  paper,  which  the  patient  is 
asked  to  keep  and  show  whenever  he  has  to  consult  a 
doctor.  Further,  they  ought  to  be  reproduced  on 
his  hospital  card  and  on  his  medical  case-sheet. 

At  the  time  of  leaving  hospital  the  doctor  must  not 
fail  to  remind  each  patient  individually  of  the  necessity 
of  continuing  treatment,  of  reporting  to  his  regimental 
doctor  the  moment  he  notices  a  symptom  of  any  kind, 
and,  even  if  there  are  no  symptoms,  to  consult  him 
from  time  to  time,  so  that  his  condition  may  be  over- 
hauled and  the  necessary  drugs  given. 

The  circular  of  September  25th,  1916,  advises, 
further,  that  cutaneous  patients  should  be  ordered  to 
have  ambulatory  treatment,  which  they  must  follow, 
and  recommends  that  only  drugs  should  be  prescribed 
which  soldiers  are  certain  of  obtaining  easily,  especially 
at  the  Front. 

Post-hospital  Treatment  and  Supervision 

The  syphilitic  who  returns  to  his  unit  after  hospital 
treatment  must  be  kept  under  observation  by  the 
regimental  doctor. 

In  order  to  do  this,  it  is  necessary  that  the  latter 
should  have  precise  knowledge  given  by  the  medical 


680  SYPHILIS  AND   THE  ARMY 

man  in  attendance.  In  times  of  peace,  military 
doctors,  instead  of  giving  the  diagnpsis  of  syphilis, 
merely  write  on  the  hospital  card  the  number  which, 
in  the  nomenclature  of  diseases  established  by  the 
public  health  service,  corresponds  to  syphilis  (No.  45) : 
45  a  primary  syphilis  ;  45  h  secondary  syphilis  ;  45  c 
tertiary  syphilis. 

The  order  given  on  September  25th,  1916,  prescribes 
that,  when  leaving  any  venereal  hospital  after  am- 
bulatory treatment  or  after  a  consultation,  a  sealed 
copy  of  the  medical  report  shall  be  sent  to  the  medical 
officer  of  the  patient's  depot,  or  of  the  establishment 
where  he  is  employed.  This  must  be  carefully  com- 
pleted, brought  up  to  date,  and  classified  in  the  report 
of  the  venereal  patients  of  the  depot.  According  to 
these  instructions,  the  report  should  follow  the  patient 
in  his  changes  of  situation,  by  direct  and  confidential 
transmission  from  one  medical  officer  to  another.  As 
far  as  possible,  the  hospital  letter  must  bear  nothing 
beyond  the  indication  of  a  lesional  diagnosis,  without 
etiological  precision. 

These  orders  answer  one  of  their  purposes  well,  that 
of  respecting  medical  secrets.  Indeed,  in  the  majority 
of  cases,  they  respond  so  well  that,  after  the  patient 
has  left  the  hospital,  no  one  has  any  notion  of  the 
malady  for  which  he  has  been  treated,  least  of  all  his 
company  doctor.  Confidential  reports  are  misleading, 
and  get  lost  in  their  multitudinous  peregrinations. 

I  consider  that,  in  the  Army,  where  the  command- 
ing officer  is  responsible  for  the  health  of  his  men, 
and  must  take  measures  to  prevent  the  propagation 
of  venereal  diseases,  medical  secrecy  is  not  opposed 
to  the  fact  that,  at  any  rate  in  war-time,  the  heads 
of  companies  should  be  aware  of  the  cases  of  venereal 
disease  contracted  by  their  men,  and  this  can  only  be 
effected  by  the  hospital  card.  It  is  their  duty,  as  with 
the  superintendents  of  hospitals  in  times  of  peace,  to 
take  precautions  so  that  their  employees  shall  not 


PROPHYLAXIS  681 

divulge  this  secret.  And,  further,  is  this  a  secret, 
having  regard  to  the  promiscuity  of  camp  life  and  of 
hospitals,  where  men  confide  so  much  to  each  other  ? 

Some  men  at  once  request  the  medical  men  not  to 
inscribe  the  diagnosis  on  their  cards  :  there  are  nearly 
always  men  who  are  trying  to  disguise  their  disease, 
so  as  not  to  be  deprived  of  leave,  who  wish  to  obtain 
sick-leave,  or  escape  later  from  the  supervision  of 
their  company  doctor. 

It  is  indispensable  that  the  regimental  doctor  should 
receive  the  instructions  given  in  the  circular  of  Sep- 
tember 25th,  1916,  and  that  no  syphilitic  should  rejoin 
his  company  without  his  being  advised  of  his  disease 
and  the  treatment  already  received. 

The  doctor  must,  according  to  the  order  of  September 
25th,  1916,  make  "  a  special  periodical  examination  of 
all  venereal  patients,  and  specially  of  those  who  have 
recently  left  hospital,  so  that  contagious  symptoms 
may  not  pass  unnoticed,  and  the  patients  may  be 
benefited  by  continuity  of  treatment  "  ;  and,  at  the 
time  of  any  change  of  station,  the  new  medical  officer 
should  be  giv^n  information  as  to  all  venereal  patients, 
especially  the  syphilitics. 

The  instructions  do  not  provide  for  restrictions  as 
to  leave  granted  to  syphilitics.  It  would  be  necessary 
to  deprive  all  syphilitics,  especially  those  who  are 
married,  of  leave  during  the  whole  period  when  con- 
tagious symptoms  are  most  liable  to  recur,  that  is  to 
say,  during  the  first  six  months  at  least,  of  syphilis. 

Munition  workers  should  be  subjected  to  the  same 
regulations  as  soldiers  in  the  regiments,  as  regards 
the  obligation  o£  reporting  the  fact  to  the  doctor, 
when  they  have  been  under  treatment  for -contagious 
syphQitic  lesions.  If  there  is  any  difficulty  in  getting 
them  to  submit  to  this  visit  outside  working  hours,  it 
would  be  quite  simple  to  replace  it  by  a  visit  to  one 
of  the  town  hospitals  or  to  a  venereal  centre.  Control 
could  easily  be  established. 


682  SYPHILIS  AND   THE  ARMY 

Measures  for  the  Purpose  of  preventing  Healthy  Men  from 
contracting  Syphilis 

These  measures  are  intended  for  the  instruction  of 
men  on  venereal  dangers,  on  the  individual  precautions 
to  be  taken  for  avoiding  contamination  ;  for  the  in- 
stallation of  establishments  for  the  treatment  of  civil 
syphilitic  patients,  and  finally  for  the  supervision  of 
prostitution. 

The  Instruction  of  Men  with  regard  to  Venereal  Danger 

Lectures  on  Venereal  Diseases. — "  If  I  had  only 
known  that  I  might  contract  syphilis,  and  what  it 
means,  I  should  not  have  run  the  risk  of  catching  it !  " 
This  is  what  every  medical  man  has  more  than  once 
heard  a  patient  say  when  told  that  he  had  syphilis, 
or  who  one  day  showed  some  grave  syphilitic  symptom, 
no  matter  whether  this  was  an  adult  who  had  contracted 
the  disease  in  some  extra-conjugal  intercourse,  or  an 
adolescent  affected  the  first  time  he  had  connection 
with  a  woman. 

As  a  result  of  this  ignorance  of  many  men  with 
regard  to  syphilis  and  the  sources  of  its  infection, 
anti- venereal  prophylactic  measures  have  been  urged, 
to  which  more  and  more  importance  has  been  attached 
of  recent  years.  Before  the  war,  army  doctors  had 
received  instructions  to  institute  periodical  lectures 
for  the  men,  in  which  venereal  diseases,  their  dangers 
and  precautionary  measures,  were  discussed;  it  has 
even  been  proposed  that  such  lectures  should  be 
included  in  the  educational  programmes  of  schools  and 
colleges. 

For  my  own  part,  I  doubt  the  efficacy  of  these 
lectures.  I  have  seen  too  many  men  expose  them- 
selves to  infection  and  become  infected,  despite  the 
fact  that  serious  cases  of  syphilis  had  come  under  their 
notice  ;    I  have  seen  too  many  young  men,  who  had 


PROPHYLAXIS  683 

been  educated  in  the  most  judicious  manner  as  regards 
venereal  diseases,  contract  syphilis  or  gonorrhoea. 
Finally,  I  have  seen  too  many  medical  students  and 
doctors  become  syphilitic  during  their  student  days, 
or  when  in  practice,  not  to  be  somewhat  sceptical  as 
to  the  results  of  educating  young  people  on  the  subject 
of  anti- venereal  prophylaxis. 

It  is  a  particularly  delicate  matter  to  give  this 
instruction.  In  an  audience  of  young  people,  even 
when  belonging  to  a  class  socially  homogeneous,  all 
have  not  similar  ideas  on  sexual  questions,  and,  in  order 
to  be  both  understood  and  useful,  the  teaching  should 
be  adapted  to  the  previous  knowledge  of  the  subject, 
as  well  as  to  the  moral  tendencies  of  each  of  the 
audience.  In  an  audience  in  which  some  unruly 
subjects  may  turn  some  expression  or  other  of  the 
lecturer  into  derision  during  or  after  the  lecture,  this 
is  sufficient  to  destroy  entirely  the  good  effect. 

Individual   sexual   instruction,   given  by  a   highly 
conscientious  man  with  sufficient  medical  knowledge 
capable  of  adapting  himself  to  the  special  conditions 
of  each  adolescent,  such  as  is  given  in  certain  secondary 
schools,  and  which  can  be  given  by  the  father  of  a 
family,  or  the  family  doctor,  is  of  real  value  in  warning 
young  people  against  venereal  diseases^  but  this  can 
only  be  carried  out  with  great  reserve,  and,  no  matter 
how  tactfully  done,  does  not  always  attain  its  object. 
In  the  Army  it  is    obviously  impossible  to  realise 
this    individual    instruction,    as    it    means    unlimited 
leisure  on  the  part  of  the  doctor.     Nevertheless,  the 
regimental    doctor    should    interest   himself  in    the 
matter.     I  understand,  from   several  young  doators, 
that  they   have   had  the   opportunity  of   discussing 
venereal  diseases  with  their  men,  and,  having  gained 
their  confidence,    have    been    able  to    impress    them 
with  ideas  from   which  they  have   derived  benefit. 
Amongst  the  services  which  a  regimental  doctor  may 
render  to  the  Army,  if  he  understands  his  work  well 


684  SYPHILIS  AND   THE  ARMY 

and  knows  how  to  mix  with  the  men  and  gain  their 
confidence,  while  at  the  same  time  keeping  up  the 
prestige  of  his  authority  and  of  his  science,  not  the 
least  is  the  prevention  of  venereal  disease.  By  means 
of  private  conversations,  the  doctor  can  increase  the 
efiicacy  of  the  lectures  given  to  units,  according  to 
regulation  orders.  Often,  too,  when  talking  with 
subalterns  at  mess,  it  will  be  easy  for  him  to  educate 
them  on  venereal  matters,  showing  them  the  dangers 
and  preventive  methods,  and  also  how  to  take  care 
of  themselves.  Thanks  to  the  confidence  he  has 
inspired  in  them,  they  may  rely  on  him  sufficiently 
to  come  to  him  for  treatment  at  once,  should  they 
happen  to  contract  syphilis.  Further,  he  will  show 
them  how  eminently  important  it  is  to  take  the  pre- 
cautions designed  to  prevent  contamination. 

Finally,  it  is  not  as  a  military  authority  due  to  his 
position,  but  by  moral  authority,  owing  to  the  character 
of  his  scientific  knowledge,  that  the  doctor  must  play 
his  part  in  the  individual  instruction  of  the  men  and 
the  staffs  on  venereal  diseases.  This,  if  I  may  say  so, 
is  in  his  private  capacity. 

There  remains  his  part  as  public  instructor.  Al- 
though, as  I  have  already  stated,  public  lectures  on 
venereal  diseases  do  not  seem  to  me  to  be  as  efficacious 
as  is  generally  supposed,  they  must  be  given,  never- 
theless, because  they  are  according  to  regulation,  and 
also  may  have  a  certain  modified  influence  on  the 
propagation  of  these  diseases.  All  useful  measures, 
no  matter  how  limited  their  influence,  must  be  resorted 
to  against  the  scourge  of  syphilitic  infection. 

The  object  of  these  lectures,  as  determined  by 
ministerial  instruction,  is  to  show  men  the  dangers  of 
venereal  diseases,  the  means  of  avoiding  them,  and 
the  necessity,  if  contracted,  of  treating  and  curing  them. 
The  lecturer  must  show  briefly,  but  sufficiently 
clearly  that  all  may  understand,  the  symptoms  of 
venereal  disease,  their  manner  of  onset,  the  signs  by 


PROPHYLAXIS  685 

which  they  are  recognised,  or  by  which  theii*  existence 
may  be  suspected,  and  also  their  after-effects  and  later 
consequences.  He  must  show  them  that  syphilis  may 
bring  in  its  train  formidable  diseases  :  tabes,  general 
paralysis,  arteriosclerosis,  that  it  affects  future  genera- 
tions, knis  children  before  birth,  and  causes  grave 
degeneration  in  them. 

These  diseases  are  generally  transmitted  by  direct 
contact,  and  are  nearly  ahvays  of  venereal  origin, 
but  they  may  be  due  to  accidental  contagion.  Conse- 
quently, they  would  be  almost  certainly  avoided  if 
sexual  intercourse  were  abstained  from.  Here  the 
lecturer  should  show\.  especially  if  he  is  addressing 
recruits,  that  continence  is  never  the  cause  of  any  ill- 
ness or  disorder,  and  that  a  man  may  abstain  from 
sexual  relations  without  any  danger,  contrary  to  the 
general  opinion  amongst  the  young. 

He  must  show  how  dangerous  women  are  who  give 
themselves  up  to  uncontrolled  clandestine  prostitution, 
such  as  waitressses  in  restaurants,  etc.,  but  at  the 
same  time  he  must  not  guarantee  that  controlled 
prostitutes  can  be  absolutely  relied  upon. 

He  should  also  recommend  that,  no  matter  what 
women  a  man  has  intercourse  with,  he  should  use  a 
rubber  protector,  or  applications  of  ointments,  etc. 
('see  p.  QS^). 

If,  in  default  of  these  precautions,  or  even  in  spite 
of  them,  symptoms  of  venereal  disease  develop,  the 
soldier  must  at  once  consult  the  regimental  doctor. 
By  doing  this,  he  wiQ  be  certain  of  not  being  pun- 
ished as  he  w^ould  be  if  he  waited  until  the  disease 
was  discovered  ;  he  w^lH  also  be  sure  of  being  properly 
treated  ;  whereas,  if  he  follows  the  advice  of  a  comrade, 
he  runs  the  risk  of  being  badly  looked  after,  and  of 
suffering  all  the  consequences  of  the  disease ;  and  if 
he  goes  to  a  quack,  or  to  some  pretended  anti-venereal 
institute,  he  will,  at  the  same  time,  be  badly  treated 
and  spend  a  lot  of  money. 


686  SYPHILIS   AND   THE  ABMY 

It  is  well  to  add  that  the  treatment  of  syphilis 
should  be  prolonged,  in  order  to  avoid  evil  consequences 
both  for  the  patient  himself  and  for  future  generations. 
Of  course,  the  lecture  must  conclude  with  a  patriotic 
note  on  the  dangers  of  syphilis  for  the  race,  and 
the  soldier  should  be  told  that,  if  he  wishes  to  avoid 
giving  the  disease  to  his  wife,  or  the  sweetheart  who  is 
waiting  to  marry  him  after  the  war,  if  he  wishes  to 
have  a  healthy  family,  whose  future  is  secured  by  his 
bravery,  he  must  keep  clear  of  venereal  diseases. 

Such  are  the  chief  points  in  these  lectures.  Accord- 
ing to  the  different  military  centres  in  which  they  are 
held,  recruits,  units  already  formed,  the  territorial 
army,  munition  workers,  etc.,  certain  paragraphs  may 
be  amplified  or  cut  down  to  suit  the  occasion. 

There  can  be  no  question  here  of  giving  the  medical 
men  appointed  for  delivering  these  lectures  more 
than  general  indications.  According  to  the  centre, 
the  intelligence  of  the  audience,  and  the  knowledge 
he  has  of  any  local  danger  of  contamination,  the 
lecturer  will  know  how  to  vary  his  effects.  He  must 
never  forget,  above  all,  that  his  audience  is  a  very 
mixed  one,  completely  ignorant  of  medical  terms,  and 
that  he  must  use  expressions  capable  of  being  under- 
stood by  all,  even  if  they  are  defective  from  a  medical 
point  of  view,  and,  if  possible,  they  must  be  graphic. 
Without  becoming  trivial,  he  must  not  forget  that 
iie  must  speak  the  language  of  the  people  who  are 
listening  to  him,  to  a  certain  extent ;  he  must  call 
gonorrhoea  "  clap,"  and  syphilis  "  pox  "  or  "  great 
pox  ' ' — and  must  not  fail  to  mention  that  it  has  nothing 
in  common  with  small-pox — and  should  call  simple 
chancre  "  soft  chancre." 

If  the  lecturer  can  get  some  drawings,  prints, 
photographs,  or  models  representing  the  principal 
forms  of  venereal  disease,  he  should  not  miss  showing 
them  to  his  audience.  Whenever  possible,  they  should 
be  thrown  upon  a  screen,   a  mode  which  specially 


PROPHYLAXIS  687 

impresses  the  masses.     All  these  illustrations  must  be 
very  simple,  and  clear. 

The  sexual  and  anti- venereal  education  of  men  is 
not  done  only  by  word  of  mouth.  In  order  that  oral 
instruction  remains  fixed  in  the  memory,  it  must  be 
corroborated  by  some  printed  matter. 

After  the  lectures,  it  will  be  necessary,  if  this  distri- 
bution has  not  already  been  made,  to  give  to  each 
of  the  audience  a  brief  account  of  venereal  diseases 
and  their  prophylaxis.  This  should  be  in  the  form 
of  a  summary  of  the  lectures  as  much  as  possible  ;  it 
should  be  enlarged  more  or  less,  in  the  form  of  a  leaflet, 
which  should  be  typed  and  copied  in  the  office  of  the 
battalion.  In  default  of  this  summary  by  the  medical 
lecturer,  which  has  the  advantage  of  being  better 
adapted  to  the  needs  of  the  unit  before  whom  the 
lectures  have  been  given,  some  of  the  pamphlets 
published  on  this  subject  may  be  distributed. 

Distribution  to  the  Troops  of  Pamphlets  on  Venereal 
Diseases. — Since  the  beginning  of  the  war,  pamphlets 
on  contagious  diseases  have  been  printed  for  the  use 
of  soldiers.* 

These  pamphlets,  which  the  men  can  read  at  leisure, 
or  ask  their  officers  or  doctors  to  explain  to  them,  are 
very  useful,  and  the  Public  Health  Authorities  have 
rendered  a  great  service  by  printing  them. 

With  regard  to  venereal  diseases,  one  pamphlet  has 
been  brought  out  by  the  Academy  of  Medicine,  and 
another  printed  by  the  Public  Health  Service  in  a 
small  leaflet  distributed  to  the  troops  at  the  beginning 
of  1916.  These  instructions  constitute  an  important 
weapon,  and  their  distribution  should  be  encouraged 
in  every  way  possible.  I  consider  that  they  form  an 
indispensable  complement  to  the  lectures,  and  may 
have  even  a  greater  influence  than  the  latter  on  serious 

*  Following  out  the  same  idea,  pictorial  anti- venereal  propaganda 
are  recommended,  the  tentative  efforts  already  made  in  Franco 
deserving  to  be  encouraged. 


688  SYPHILIS   AND   THE   AEMY 

men  with  reasoning  power,  capable  of  seeking  the 
explanation  of  the  prophylactic  measures,  and  may 
aid  the  doctors  as  an  excuse  and  subject  of  conversation 
with  the  different  men. 

In  Italy,  where  the  anti- venereal  struggle  began 
several  months  before  the  declaration  of  war,  and 
was  organised  with  extreme  care,  similar  notices  were 
distributed  on  a  large  scale.*  The  Committee  of 
Medical  Propaganda  of  Milan  caused  them  to  be  left 
in  public  places,  in  military  refreshment  bars  at  the 
railway  stations,  under  cover  of  an  envelope  bearing 
this  inscription  :  "  Italian  soldiers,  if  your  health  is 
dear  to  you,  if  you  wish  for  the  welfare  of  your  family 
and  country,  read,  mark,  and  observe  the  instructions 
contained  in  this  envelope." 

Personal  Precautions 

A  large  number  of  syphilitic  contaminations  would 
be  avoided  if  the  men  took  simple  and  well-known 
precautions  at  the  time  of  sexual  intercoui'se. 

The  first  of  these  precautions  consists  in  careful 
examination  of  the  genital  organs,  so  as  to  be  certain 
that  there  are  no  excoriations  or  sores  through  which 
contamination  might  occur. 

The  use  of  a  rubber  protector  of  good  quality,  which 
is  neither  perforated  nor  has  been  used  before,  is  a 
very  great,  if  not  an  absolute,  guarantee  against 
syphilitic  infection.  But  it  is  also  essential  that  there 
should  be  neither  sore,  excoriation  from  scratching, 
nor  parasite,  such  as  the  pediculus  pubis,  on  any  of 
the  adjoining  regions  not  covered  by  the  protector 
(pubis,  inside  of  thighs). 

Failing  a  rubber  protector,  it  is  nearly  always 
possible  to  rub  an  ointment  into  the  whole  of  the 

*  Pasini,  "  Cio  che  si  fa  nella  sede  del  III.  Corpo  d'armata  per 
la  profilassi  della  malattie  veneree "  (Giornale  italiano  d^Ue malattit 
verteree  e  della  pelle,  1915,  fasc.  v.); 


PROPHYLAXIS  689 

surface  of  the  genital  organs,  vaseline  by  preference, 
which,  by  preventing  direct  contact  with  the  virulent 
secretions,  resists  contagion  to  a  certain  extent. 

After  coitus,  washing  with  soap  and  water  is  a  useful 
prophylactic  measure.  This  should  be  done  as  quickly 
as  possible,  using  plenty  of  soap,  especially  over  the 
glans  and  frenum.  Soap  is  a  well-known  antiseptic 
for  various  kinds  of  parasites  ;  the  treponema  of 
syphilis,  which  is  easily  vulnerable,  does  not  seem  able 
to  resist  it  any  more  than  Ducrey's  bacillus.* 

More  or  less  concentrated  alcohol  may  also  serve  for 
sterilising  virulent  syphilitic  products ;  this  is  known 
to  be  the  most  certain  and  practical  way  of  disin- 
fecting a  doctor's  hands  after  examining  syphilitic 
patients. 

In  default  of  soap  and  alcohol,  continued  washing 
with  pure  water  or  with  the  addition  of  sublimate  may 
be  done. 

As  the  result  of  experiments  on  apes,  in  which 
inoculation  of  syphilitic  products,  followed  by  energetic 
friction  with  calomel  ointment,  remained  negative, 
Metchnikoff  recommended  friction  with  an  ointment 
containing  33%  of  calomel,  as  a  means  of  preventing 
syphilis. 

A  certain  number  of  patients  having  developed 
syphilitic  chancres  after  using  this  ointment,  Metchni- 
koff's  preventive  method  has  been  denounced  by  the 
majority  of  medical  men.  Probably  it  merited  neither 
this  reprobation  nor  the  value  attributed  to  it  by 
Metchnikoff.     If  used,  it  should  be  preceded  by  wash- 


♦  The  experiments  of  Giovannini  ("  Tentativi  di  disinfezione  di  fer- 
ite  infette  con  pus  di  ulceri  veneree  per  mezzo  del  sapone  comune  " 
{Gazzetta  medica  di  Torino,  1898,  Nos.  45  and  46)  have  shown  that 
washing  with  soap  and  water  acts  very  energetically  on  the  bacillus 
of  simple  chancre :  out  of  twenty-one  experiments,  a  chancre  only 
developed  ten  times.  The  most  favovirable  conditions  for  success 
in  washing  are  the  superficial  character  of  the  sore  (sore  by  abrasion) 
the  small  quantity  of  \arus  on  its  surface,  the  short  time  that  has 
elapsed  between  infection  and  soaping,  and  prolongation  of  soaping. 


690  SYPHILIS  AND   THE  ARMY 

ing  with  soap,  of  which  it  strengthens  the  action  and 
should  follow  immediately  upon  suspected  coitus.* 

Ministerial  circulars,  dating  froni  September  23rd, 
1907,  and  November  16th,  1907,  order  that  calomel 
ointment  should  be  supplied  to  the  regimental  hospitals. 

Creation  of  Centres  for  the  Treatment  of  Syphilis  amongst 
the  Civil  Population 

For  the  last  fifteen  years,  the  staffs  of  special  hospitals 
have  treated  patients  suffering  from  syphilis  as  out- 
patients, without  interning  them. 

In  Paris,  drugs  are  distributed  on  a  large  scale  for 
the  treatment  of  syphilis  by  the  special  hospitals  (Saint 
Louis,  Broca,  Cochin). 

The  general  use  of  mercurial  injections  has  greatly 
facilitated  the  ambulatory  treatment  of  syphilis. 
Since  1902,  my  colleague  Brocq  and  I,  at  the  Broca 
Hospital,  have  given  out-patient  treatment  to  syphilitic 
women  on  a  large  scale  ;  since  then,  nearly  all  special 
hospitals  have  added  poly  clinics,  to  their  departments 
for  syphilitic  treatment,  by  means  of  mercurial  in- 
jections. 

More  recently,  the  use  of  arsenical  compounds  has 
enabled  these  polyclinics  to  render  still  more  help,  by 
realising  the  energetic  treatment  of  syphilis,  especially 
during  the  primary  periods,  without  sending  the 
patient  to  hospital.  The  dispensaries  t  attached  to 
certain  services  consist  of  the  old  polyclinics,  enlarged, 
brought  up  to  date,  and  supplied  with  a  complete  staff. 
Consultations  on  a  Sunday,  as  well  as  in  the  evening, 
have  made  it  possible  for  all  patients,  especially  work- 
men, to  be  treated  in  an  efficacious  manner. 

*  Syphilis  is  not  the  only  venereal  disease  against  which  pre- 
cautions should  be  taken  after  coitus.  I  shall  not  go  into  details 
with  regard  to  gonorrhopa,  as  I  am  only  concerned  with  syphilis  here. 

t  Jeanselme  and  Hudelo,  "  The  Part  played  by  the  Dispensaries 
at  the  Broca  Hospital  in  the  Campaign  against  Syphilis"  {Bulletin 
de  VAcademie  de  Medecine,  March  28th,  1916,  p.  364). 


PROPHYLAXIS  691 

Alfred  Fournier  specially  recommended  the  gener- 
alisation of  these  centres  for  treatment,  having  demon- 
strated their  share  in  the  prophylaxis  of  syphilis,  and 
devoted  several  publications  to  what  he  called  Prophy- 
laxis by  means  of  treatment. 

What  has  been  done  in  Paris  has  also  taken  place  in 
the  majority  of  the  large  centres. 

It  is  certain  that  the  more  establishments  there  are 
for  patients,  where  they  can  be  treated  gratuitously, 
the  more  chance  is  there  of  their  being  treated.  The 
better  these  establishments  are  organised  for  treatment, 
the  more  rapid  will  be  the  cure  of  contagious  syphilitic 
lesions,  and  consequently  the  fewer  the  number  of 
patients  capable  of  transmitting  the  disease  and  the 
less  the  chances  of  contamination. 

The  polyclinics  ,and  dispensaries  for  patients  who 
cannot,  or  will  not,  be  treated  in  hospital,  and  the 
hospital  services  open  to  syphilitics,  especially  con- 
tagious cases  which  cannot  be  treated  at  home  or 
whose  symptoms  require  special  attention,  constitute 
two  complementary  organisations.  The  first  is  recom- 
mended, owing  to  the  small  expense  it  incurs,  both  for 
public  money  and  for  the  patients  themselves,  who 
can  continue  work  while  under  treatment  ;  the  second 
has  the  great  advantage  that,  while  giving  more  ener- 
getic treatment  than  the  first,  it  withdraws  from  circu- 
lation patients — men  and  women — during  the  period 
they  are  contagious. 

These  two  can  be  created  by  the  hospital  adminis- 
tration without  difficulty  or  large  expense,  and  without 
legal  intervention.  Subjected  to  the  same  freedom 
of  action  as  the  hospitals,  they  receive  the  patients 
who  come  spontaneously,  without  any  coercion  from 
the  police. 

The  difficulties  with  regard  to  working  them  are 
more  trouble  to  overcome,  especially  in  time  of  war. 

Both  military  and  civil  authorities  have  realised  the 
importance   of  increasing  hospital   resources  for  the 


692  SYPHILIS  AND   THE  ARMY 

treatment  of  venereal  patients.  Their  union  has  been 
genuinely  fruitful,  and  their  combined  initiative  has 
given  all  syphUitics — both  men  and  women — the 
facility  for  treatment  they  desire,  and  will  do  so  still 
more  in  the  future. 

Under  the  inspiration  of  two  eminent  hygienists, 
Medical  Inspector  General  Vaillard  and  M.  Brisac, 
Director  of  Public  Assistance  and  Hygiene  to  the 
Minister  of  the  Interior,  M.  Malvy,  Minister  of  the 
Interior,  and  M.  Justin  Godart,  Under-Secretary  of 
State  for  the  Military  Medical  Service,  came  to  a  perfect 
agjreement,  in  March  1916,  as  to  the  necessary  measures 
to  be  taken  for  the  creation,  extension,  and  working 
of  the  special  services  and  of  dermato-venereological 
consultations. 

The  Minister  of  the  Interior  decided  on  the  creation 
of  special  services  with  dispensaries,  caUed  additional 
hospital  services,  in  aU  the  localities  where  the  number 
of  venereal  patients  rendered  it  necessary,  and  where 
it  was  possible.  These  offer  all  facilities  to  patients 
who  have  contracted  these  diseases,  so  that  they  may 
be  treated  gratuitously  and  with  absolute  secrecy. 

These  additional  services,  established  principally  in 
localities  depending  upon  the  hospital  establishments 
themselves,  are  set  up  in  all  localities  where  regional 
military  authority,  in  conjunction  with  the  local  civil 
authorities,  indicate  the  necessity. 

Owing  to  the  paucity  of  civil  surgeons  in  many 
localities,  the  medical  service,  when  necessary,  is 
assisted  by  military  surgeons. 

A  certain  number  of  additional  services  were  soon 
organised,  and  enable  one  to  establish,  at  the  same 
time,  their  important  part  and  the  conditions  of  their 
organisation  and  Working. 

By  a  circular,  dated  May  21st,  1916,  the  Minister 
of  the  Interior  advised  the  prefects  to  generalise  the 
creation  of  these  services,  and,  in  conjunction  with 
the  Regional  Direction  of  the  Medical  Service,  to  use 


PROPHYLAXIS  693 

their  authority  with  the  administrative  commissions 
of  the  hospitals  and  asylums,  so  that  they  should  be 
set  up  in  all  necessary  localities.  As  it  concerned  a 
service  of  general  interest,  it  was  announced  that 
the  State  would  share  in  the  expense  caused  by  their 
organisation  and  working. 

The  additional  services  have  been  created  in  a  large 
number  of  localities  outside  large  towns,  where  they 
have  extended  the  services  of  venereology  and  dermat- 
ology of  peace  times.  Their  extent  and  resources  vary 
in  accordance  with  the  importance  of  the  civil  and  mili- 
tary populations. 

Their  working  is  carried  out  nearly  everywhere  by 
military  doctors,  especially  by  the  medical  men  who 
are  heads  of  dermato-syphiligraphic  centres  and  sub- 
centres,  or  by  others,  not  mobilised,  in  charge  of 
prostitutes. 

In  some  districts,  the  local  authorities  offered  some 
opposition  to  the  formation  of  these  dispensaries  ;  but, 
as  a  rule,  they  have  taken  an  active  interest  in  the 
Army  Medical  Service. 

The  results  appear  to  have  been  remarkable,  the 
number  of  considtations  having  increased  rapidly ; 
thanks  to  the  activity  of  the  doctors,  and  despite 
the  defectiveness  of  certain  localities,  the  treatment 
of  syphilis  has  been  installed  under  good  conditions. 
It  is  only  right  here  to  mention  that  the  zeal  of  some 
medical  chiefs  of  centres,  amongst  whom  I  have 
pleasure  in  citing  Dr.  Pautrier,  Head  of  the  Dermato- 
syphiligraphic  Centre  at  Bourges,  has  soon  given  tone 
and  example  to  these  assistant  services. 

From  experience  acquired,  in  order  to  facilitate  the 
entrance  of  patients  to  the  additional  dispensaries, 
it  is  advisable  not  to  confine  them  exclusively  to 
venereal  diseases,  but  to  use  them  for  both  dermato- 
logical  and  venereal  cases. 

For  reasons  easy  to  understand,  the  additional 
services   must   be   separated   from   the   localities   in 


694  SYPHILIS  AND   THE  ARMY 

which  diseased  prostitutes  are  detained.  On  the  other 
hand,  however,  they  are  suitable  for  the  treatment  of 
women  who  have  given  themselves  up  to  clandestine 
prostitution,  and  having  been  arrested  and  found 
to  be  diseased,  cannot,  under  the  terms  of  the  present 
law,  be  kept  under  arrest,  because  they  do  not  live 
solely  by  prostitution,  but  to  whom  the  police  are 
compelled  to  recommend  treatment. 

Beyond  this  recruiting  by  administrative  agency, 
syphilitics  can  only  be  led  to  the  additional  dispen- 
saries by  persuasion,  or  attracted  there  by  the  reputa- 
tion of  these  services.  Medical  men  may  institute 
a  useful  propaganda  by  getting  their  poor  patients 
to  go  there ;  but,  above  all,'^it  is  necessary  that  the 
civil  authorities  should  make  known  their  existence 
by  discrete  publicity  ;  and  the  managers  of  work- 
shops and  industrial  concerns  should  persuade  their 
workpeople  to  go  there,  when  attacked  by  venereal 
diseases. 

These  additional  services  will  obtain  their  recruits 
by  their  work  ;  patients  who  have  recovered  will 
gradually  tell  their  fellow-workmen  suffering  from 
cutaneous  or  venereal  disease. 

It  is  to  be  hoped  that,  after  the  war,  these  additional 
dispensaries,  established  through  necessity,  will  con- 
tinue to  carry  out  the  treatment  of  venereal  patients 
in  a  certain  number  of  towns,  outside  large  centres, 
where  they  have  been  generally  neglected,  and  dissipate 
certain  prejudices  with  regard  to  these  patients. 

The  Supervision  of  Prostitution 

Essentially,  the  additional  dispensaries  and  gratuit- 
ous consultations  only  receive  patients  who  have  come 
voluntarily  and  nearly  always  spontaneously.  They 
apply  solely  to  syphilitics  who  know  they  are  ill  and 
want  to  be  cured  ;  they  do  not  protect  society  either 
against  syphilitics,  who  are  ignorant  of  their  disease. 


PROPHYLAXIS  695 

nor  against  those  who,  knowing  they  are  ill,  do  not 
hesitate  to  transmit  their  disease,  rather  than  be  treated 
and  abandon  all  sexual  intercourse. 

The  expression  prophylaxis  by  treatment,  which 
has  gained  renown  from  Fournier's  great  authority, 
is  somewhat  unfortunate,  because  it  has  seemed  to 
some  to  constitute  the  only  formula  of  the  prophylaxis 
of  syphilis.  In  reality,  prophylaxis  by  treatment,  so 
much  praised  by  Fournier,  is  a  very  incomplete  prophy- 
laxis, realised  solely  by  patients  of  good  intention  ;  it 
does  not  reach  those  whose  intentions  are  evil  or  who 
are  weak-willed. 

In  order  that  a  woman  suffering  from  contagious 
syphilis  will  consult  a  doctor,  it  is  necessary  :  ( 1 )  that 
she  knows  she  needs  treatment  and  tnat  she  can  be 
treated  at  a  hospital  or  dispensary  ;  (2)  that  she  is 
willing  to  be  treated. 

Many  women  who  at  the  present  time  abandon  them- 
selves to  prostitution  have  only  the  vaguest  notions 
of  venereal  diseases  ;  many  of  those  who  have  gone 
on  to  the  streets  since  the  beginning  of  hostilities,  or 
have  yielded  themselves  to  men  at  the  back  of  a  shop, 
have  but  little  idea  of  what  may  happen  to  them  in  the 
future. 

The  majority  are  ignorant  of  the  dangers  they  are 
running  and  of  those  they  continue  to  run  until  the  day 
when,  owing  to  some  serious  or  painful  affection,  they 
are  unable  to  continue  their  business  or  are  accused  by 
one  of  their  clients  of  having  transmitted  a  disease  to 
him. 

Medical  men  in  special  hospitals  know  that  it  is 
rare  to  see  an  infective  chancre  in  a  woman.  At  the 
Broca  Hospital,  where  the  patients  consist  of  women 
living  a  free  life,  as  at  the  St.  Louis  Hospital,  not  one 
syphilitic  woman  out  of  twenty  comes  for  consultation 
owing  to  chancre  ;  most  of  them  do  not  think  of  having 
a  doctor  unless  they  have  mucous  plaques,  and  some- 
times what  a  quantity  of  these !      On  hearing  that 


696  SYPHILIS  AND  THE  ARMY 

even  the  previous  day  they  have  had  sexual  intercourse, 
the  number  of  men  they  may  have  infected  during 
the  last  six  weeks  is  terrible. 

Despite  the  circulation  among  the  people  of  in- 
structions as  to  venereal  diseases,  and  the  multi- 
plicity of  places  for  treatment,  the  spectacle  of  our 
consultations  has  not  changed. 

The  efforts  made  by  the  medical  authorities  in  spread- 
ing these  ideas  and  making  known  the  existence  and 
working  conditions  of  these  establishments  intended 
for  the  treatment  of  venereal  diseases,  no  matter  how 
admirable  and  energetic  they  may  be,  run  foul  of 
impossibilities  and  only  succeed  in  reaching  some 
factory  girls. 

Therefore,  we  cannot  count  absolutely  on  the  good- 
will of  diseased  women  with  regard  to  treatment.  In 
order  to  thoroughly  realise  the  prophylaxis  of  syphilis 
by  the  treatment  of  syphilitic  women,  persuasion, 
together  with  the  spontaneous  entry  into  hospital,  is 
insufficient.     Something  more  is  necessary. 

Since  the  authorities  have  considered  the  subject  of 
the  propagation  of  venereal  diseases,  they  have  tried, 
by  means  of  police  measures,  to  withdraw  from  circu- 
lation women  who  are  affected.  From  this  originated 
supervision  of  prostitution,  leading  to  the  arrest  of 
prostitutes,  to  medical  inspection,  to  registration  of 
those  known  to  ply  the  trade  of  prostitution,  or  who, 
in  order  to  take  advantage  of  certain  immunities 
resulting  from  registration,  ask  to  have  their  names 
inscribed  on  the  register  of  official  prostitution,  and 
finally  to  the  periodical  inspection  of  registered  women 
to  see  if  they  are  suffering  from  contagious  diseases, 
in  which  case  they  are  sent  to  hospital. 

To  this  must  be  added  the  opening  of  licensed 
houses,  under  police  supervision,  where  the  occupants 
are  subjected  to  repeated  medical  inspection. 

These  different  measures  have  aroused  numerous 
and  diverse  protests,   in  the  name  of  morality,   of 


PROPHYLAXIS  697 

individual  liberty,  often  the  result  of  an  exaggerated 
sensitiveness. 

There  is  no  doubt  that  there  have  been  abuses  in 
the  repression  of  prostitution,  that  the  officials  charged 
with  the  investigations  have  often  made  mistakes, 
and  that  unjustifiable  arrests  have  sometimes  been 
made.  All  this,  however,  is  not  sufficient  to  prevent 
society  from  protecting  itself  against  a  disease  which 
has  a  disastrous  influence  upon  public  health  and  the 
race,  which  has  become  a  social  danger,  and,  at  the 
present  time,  constitutes  a  national  peril. 

It  is  not  a  question  of  confining  women  who  lead 
an  immoral  life  as  a  punishment,  as  if  they  were  lepers, 
but  of  treating  women  who  give  themselves  up  to 
prostitution,  and  are  diseased,  and  are  liable  to  in- 
fect every  day  the  men  to  whom  they  yield  them- 
selves. It  is  necessary  that  prostitutes  should  be 
subjected  to  medical  inspection,  and  that  all  those 
found  to  be  diseased  should  be  treated,  at  least  during 
the  contagious  stages.  After  these  symptoms  have  been 
cured,  and  they  have  been  shown  hpw  to  look  after 
themselves,  they  should  be  subjected  to  repeated 
examinations  and  again  treated,  if  they  are  found  to 
have  symptoms. 

Such,  from  the  medical  point  of  view,  is  the  postulate 
of  the  prophylaxis  of  syphilis. 

As  Balzer  says,*  the  supervision  of  prostitution  is  the 
only  measure  which  can  give  the  immediate  results  which 
it  is  necessary  to  obtain  in  the  matter  of  venereal 
prophylaxis  in  the  Armies. 

The  supervision  should  apply  not  only  to  the  women 
known  by  the  police  to  practise  prostitution,  the 
registered  women,  but  also  to  those  who  solicit  in  the 
streets  and  public  places,  and  to  those  who  are  declared 
by  the  soldiers  to  be  the  origin  of  undoubted  con- 
taminations. 

*  "  Prophylaxis  and  Treatment  of  Venereal  Diseases  in  Time  of 
War"  {Presse  medicale,  October  14th,  1915,  p.  401). 


698  SYPHILIS  AND  THE  ARMY 

The  Academy  of  Medicine  was  justified  when,  at 
the  meeting  on  June  13th,  1916,  it  demanded  that 
there  should  be  police  supervision,  not  only  with  regard 
to  street  prostitution,  but  also  to  that  in  public  places. 

For  a  long  time  there  have  been  rules  ordering  a 
soldier  to  report  the  woman  who  has  contaminated 
him.  This  measure  has  often  been  criticised,  and  the 
remark  has  been  made  that  the  statements  of  men  are 
often  erroneous,  either  voluntarily  or  involuntarily, 
that  sometimes  they  knowingly  denounce  women 
who  have  nothing  to  do  with  their  disease.  Despite 
these  mistakes,  which  are  less  frequent  than  has  been 
stated^  the  men's  declarations  are  often  most  useful 
in  acquainting  the  police  with  women  who  disseminate 
sj^hilis.  These  declarations  are  made  under  the 
control  of  the  regimental  doctor,  who  must  himself 
question  the  soldiers  and  specify  the  disease  from  which 
they  are  sufiFering,  as  was  again  ordered  in  the  circular 
of  September  25th,  1916.  Thfey  must  be  transmitted 
to  the  local  police,  who  rnust  supervise  and,  whenever 
possible,  cause  the  incriminated  women  to  be  examined. 

In  the  army  zone  syphUitic  contaminations  occur,  as 
I  have  shown,  from  nearly  all  classes  of  women  who 
are  there,  especially  those  who  trade  with  the  soldiers 
in  some  form  or  another. 

To  be  efficacious,  supervision  should  apply  to  all 
women  who  may  be  suspected  of  yielding  to  men.  This 
is  the  easier  because  there  are  but  few  women  living 
in  this  zone,  and  all  are  known  to  the  military  authori- 
ties. It  is  due,  not  only  to  the  military  authorities, 
but  also  to  the  police  of  the  zone,  to  take  the  necessary 
measures,  and  the  medical  department  must  see  that 
they  are  carried  out  by  the  military  doctors. 

In  the  rest  zone,  contamination  originates  with 
women  who  live  habitually  in  the  country,  as  well  as 
numbers  of  others  attracted  there  by  the  presence 
of  the  soldiers.  Prophylactic  action  should  apply 
to  one  as  much  as  to  the  others.     It  is  the  duty  of 


PROPHYLAXIS  699 

both  military  and  civil  authorities,  and  can  only  be 
efficacious  on  condition  that  there  is  a  close  under- 
standing between  the  two  authorities.     Here,  again, 
the   military   doctors  are  the  ones  who  have  most' 
frequently  to  guarantee  the  medical  part  of  the  service. 

At  the  base,  the  great  majority  of  contaminations 
are  due  to  women  on  the  streets  and  servants  in  restaur- 
ants and  public-houses.  Supervision  should  be  given 
in  the  streets,  especially  around  the  stations  and 
near  the  factories  when  the  workmen  are  leaving  ; 
but  not  only  on  the  large  boulevards,  as  in  peace  time, 
and  at  night-fall,  but  at  all  times  and  in  a  very  large 
number  of  streets.  This  supervision  must  not  be 
exercised  solely  on  women  known  to  the  police. 

Borne  *  says,  with  regard  to  police  supervision  in 
Paris  since  the  war  :  "  The  public  authorities  have 
moved,  and  the  prefecture  of  police  has  given  orders, 
to  arrest  girls  and  their  bullies  around  the  stations  ; 
but,  as  figures  would  be  necessary  to  satisfy  public 
opinion,  special  brigades  have  assembled  the  registered 
women  well  known  to  them.  These,  according  to 
the  authority  of  the  prefecture  of  police  whom  we 
consulted,  are  contagious  in  the  proportion  of  10% 
only,  for  the  inspection  and  prophylaxis  of  licensed 
women  have  continued  to  be  enforced  rigorously  and 
regularly  during  the  war,  so  that  there  are  90%  of 
healthy  women  subjected  to  each  drive." 

Two  words  only  on  the  question  of  licensed  houses. 

Although  the  security  they  give  to  their  clients  is 
only  relative,  and  syphilitic  infection  is  not  rare  in 
them,  these  establishments,  when  well  supervised, 
play  an  important  part  in  the  prophylaxis  of  venereal 
diseases. 

It  is  necessary  that  they  should  be  visited  frequently 
and  unexpectedly.     With  the  afflux  of  clients  the  war 

*  Borne,  "  Hygiene  of  the  Soldier  on  Leave  in  Paris.  Prophy- 
laxis of  Contagious  Diseases"  {Paris  medicale,  August  12th,  1916, 
p.   133). 


700  mrPHILIS  AND  THE  ARMY 

brings  them,  both  in  the  army  zone  and  at  the  base, 
these  visits  must  be  made  daily,  as  required  by  the 
Academy  of  Medicine.  It  is  imperative  that  the 
medical  men  in  charge  should  have  at  their  disposal 
a  sufficiently  lighted  place  for  examination,  and  the 
necessary  instruments.  The  co-operation  of  the  mili- 
tary doctors  is  to  be  counted  on  in  all  localities  where 
the  absence  of  competent  civil  surgeons  renders  it 
useful. 

In  the  Manchurian  War  the  Japanese  installed  free 
licensed  houses,  subjected  to  regular  medical  visits,  and 
attributed  to  this  the  very  small  venereal  morbidity 
of  their  Army  ;  whereas, .  with  the  Russians,  the 
number  of  venereal  patients  was  very  high. 

In  the  Italian  Army,  which  was  supplied  with 
licensed  houses  during  the  Syrian  War,  the  Powers 
have  organised  licensed  houses  even  in  the  localities 
near  the  Austro-Italian  Front. 

To  return  to  free  prostitution. 

When  a  woman  is  known  to  be  a  regular  prostitute, 
has  been  arrested  several  times,  and  is  suffering  from 
contagious  lesions,  when,  above  all,  these  lesions  have 
recurred  after  a  preliminary  treatment,  or  she  has 
not  been  treated  after  being  warned,  she  should  no 
longer  be  advised,  but  compelled  to  have  treatment.  In 
these  conditions,  according  to  the  custom  in  Paris, 
she  must  have  her  name  inscribed  on  the  list  of  pros- 
titutes, and  be  subjected  to  all  the  obligations  neces- 
sitated by  registration. 

Registered  women,  at  their  own  request,  or  as  an 
administrative  measure,  must  be  subjected  to  regular 
and  frequent  medical  examination.  In  Paris  they 
are  expected  to  present  themselves  at  the  Prefecture 
of  Police  for  a  medical  inspection  twice  a  month,  on 
dates  of  their  own  selection.  This  periodicity  is 
altogether  inadequate  :  the  security  given  men  who 
have  relations  with  women  of  this  class  is  never  more 
than  relative  ;   it  is  almost  nil  with  bi-monthly  visits. 


PROPHYLAXIS  701 

These  should  take- place  at  least  twice  a  week  if  real 
prophylactic  results  are  to  be  obtained.  Any  woman 
found  to  be  affected  when  examined  should  be  at 
once  sent  to  the  place  where  prostitutes  are  treated, 
and,  as  I  have  already  mentioned,  this  should  be  inde- 
pendent of  the  additional  hospital  services,  There 
she  will  be  treated  actively,  and  not  discharged  until 
the  contagious  symptoms  have  disappeared. 

The  "registered"  women,  fenown  to  be  syphilitic, 
are  given  a  card  of  a  special  colour  in  Paris,  and  obliged 
to  submit,  during  two  years,  to  a  weekly  inspection. 
All  facilities  for  being  treated  should  be  given  them, 
by  means  of  consultations  at  the  additional  hospitals. 

For  the  execution  of  such  measures,  the  collabora- 
tion of  both  civil  and  military  authorities  is  necessary. 
In  all  localities  where  the  paucity  of  civil  surgeons 
does  not  allow  regular  examination  of  prostitutes, 
instructions  were  given  on  September  25th,  1916, 
ordering  the  army  doctors  to  participate  in  this  service. 
In  the  army  zone,  by  regulation,  the  commanding 
officer  may  order  a  military  doctor  to  assist  in 
examining  the  women  in  question,  when  this, examina- 
tion is  made  by  a  civil  surgeon. 

In  the  army  zone,  the  majority  of  these  measures 
relative  to  the  supervision  of  prostitutes  are  carried 
out,  owing  to  the  power  vested  in  the  commanding 
officer. 

The  same  applies  to  a  certain  number  of  ihland 
towns,  where  the  collaboration  of  a  venereal  specialist, 
an  energetic  medical  officer  of  health,  a  prefect  under- 
standing his  hygienic  mission,  and  a  municipality 
stripped  of  prejudice,  has  enabled  all  desirable 
measures  to  be  taken,  and  the  result,  in  aU  these  towns, 
has  always  been  a  reduction  of  venereal  contamination. 
In  very  many  localities  in  the  rest  zones  and  in  the 
interior,  there  is  still  much  to  be  done,  and  it  is  necessary 
that  measures  should  be  taken. 

They  can  only  be  effected,  at  the  present  time,  by 


702  SYPHILIS  AND   THE  ARMY 

the  good-will  of  the  municipalities,  who  hold  the 
necessary  powers  for  the  order  and  execution  of  the 
medical  regulations. 

Consequently,  for  local  reasons,  some  municipalities, 
not  having  sufficient  understanding  of  the  present 
necessities  and  of  the  interest  of  the  whole  nation, 
hesitate  or  refuse  to  regulate  the  supervision  of  pros- 
titution. 

Some  have  judicial  scruples  and  do  not  consider 
that  they  are  authorised  to  make  the  necessary  arrests. 
The  question  of  legality  appears  to  be  decided  by 
jurisprudence. 

As  a  matter  of  fact,  in  February  1915,  the  Minister 
of  the  Interior  announced  to  the  prefects  and  mayors 
that  the  Court  of  Appeal  recognised  that  the  municipal 
authority  had  the  right  to  enter  the  names  of  clandes- 
tine prostitutes  on  the  police  register  and  to  compel 
them  to  submit  to  medical  inspection,  including  the 
interdictidli  of  soliciting,  or  even  of  gathering  around 
certain  public  establishments. 

The  mayors  may,  therefore,  take  the  most  important 
of  the  necessary  measures  ;  in  default  of  their  initiative, 
or  in  the  presence  of  their  inertia,  the  public  authorities 
must  not  remain  disinterested,  and  it  is  urgent  that, 
wherever  this  is  necessary,  the  prefects  may  take  this 
problem  in  hand  and,  with  the  authority  they  possess, 
enforce  the  necessary  regulation. 

In  Italy,*  where  for  years  the  relative  liberty  of 
prostitution,  due  to  the  "  Crispi  regulations,"  favoured 
the  considerable  extension  of  syphilis,  and  where 
rational  measures  were  taken  at  the  beginning  of  the 
campaign,  the  Minister  of  the  Interior,  supported  by  a 
decree  of  the  Lieutenant- General  of  the  Kingdom,  did 

*  Balzer,  "  Anti-venereal  Prophylaxis  by  Civil  and  Military 
Administration"  [Presse  medicale,  January  13th,  1916,  p.  10). 
Clement  Simon,  "  Report  presented  to  the  Minister  of  the  Interior 
and  the  Under-Secretary  of  State  for  Medical  Services  on  the  Anti- 
venereal  Prophylactic  Organisation  in  Italy"  {Annalea  des  maladies 
veneriennes,  October  1916,  p.  577). 


PROPHYLAXIS  703 

not  hesitate  to  write  on  September  11th,  1915  :  "  Pre- 
fects henceforth  may  adopt  the  strictest  and  most 
rigorous  measures,  even  sacrifice  of  the  principle  of 
individual  liberty,  in  the  public  interest." 

If  administrative  authority  does  not  consider  itself 
sufficiently  armed  for  the  combat  against  the  pro- 
pagation of  syphilis  by  repressing  prostitution,  it  is 
necessary  that  it  should  be  reinforced. 

The  superior  interest  of  public  health  has  already 
caused  the  intervention  of  legislation,  by  ordering 
anti-variolic  vaccination,  and,  a  short  time  before  the 
war,  anti-typhoid  inoculation,  measures  the  efficacy 
of  which  has  been  happily  demonstrated  by  the 
disappearance  of  small-pox  and  the  considerable 
diminution  of  the  number  of  cases  of  typhoid  fever. 
This  interest  is  no  less  compromised  by  the  propagation 
of  syphilis,  which,  as  I  showed  at  theheginning  of  this 
book,  is  a  present,  as  well  as  a  future,  menace  to  the 
country.  It  is  time  that  measures  were  taken  to  check 
this  propagation.  It  is  the  duty  of  the  public  authori- 
ties, the  legislators  if  necessary,  to  take  all  the  requisite 
measures,  even  should  they  require,  for  the  benefit  of 
the  community,  the  restriction  of  individual  liberty. 
The  regular  supervision  of  prostitution  and  its  repression 
are  necessities,  both  at  the  present  time,  and  after  the 
war.  Every  one  must  bear  his  responsibility  in  this 
question,  without  any  regard  to  secondary  considera- 
tions, political  or  otherwise. 


SECTION  IV 

THE  ABNORMAL 
FORMS  OF  TETANUS 


THE  ABNORMAL  FORMS  OF 
TETANUS 

PART   /.—THE  KNOWN  ATYPICAL 
FORMS  OF  TETANUS 

The  various  manifestations  of  the  tetanic  infection 
permit  of  the  differentiation  of  a  great  variety  of 
cUnical  forms. 

According  to  the  development  of  the  disease,  the  pre- 
dominance of  certain  indications,  the  etiology  of  the 
case,  and  its  severity,  we  may  describe  a  whole  series 
of  individual  forms. 

Many  of  these  fall  under  the  heading  of  the  classic 
tetanus,  and  do  not  constitute  atypical  forms.  Thus, 
for  example,  the  super-acute  forms  of  tetanus  are  merely 
a  particular  modality  of  the  disease  dependent  upon 
the  gravity  of  the  symptoms  immediately  after  their 
appearance.  It  follows,  therefore,  that  sphlancnic 
tetanus  is  not,  properly  speaking,  an  atypical  form. 
We  shall  mention  it  only,  without  enlarging  upon  it, 
for  if  the  contractions  are  not  generalised  the  cause  is 
to  be  found  principally  in  the  very  rapid  development 
of  the  disease  and  its  fatal  termination  within  twenty- 
four  to  forty-eight  hours. 

On  the  other  hand,  cephalic  tetanus  is  a  truly  atypical 
and  partial  form  of  the  infection  ;  we  shall  accordingly 
examine  its  four  varieties,  which  are  : 

1.  Cephalic  tetanus  without  paralysis. 

707 


708    THE  ABNORMAL  FORMS  OF  TETANUS 

2.  Cephalic  tetanus  with  facial  paralysis. 

3.  Cephalic  tetanus  with  paralysis  of  the  motor 
nerves  of  the  eye. 

4.  Cephalic  tetanus  with  paralysis  of  the  hypoglossal. 
Having  examined  each  of  these  forms,   we  shall 

terminate  this  chapter  by  a  rapid  summary.  We 
propose  in  this  to  show  that  the  varieties  of  cephalic 
tetanus  are  merely  modifications  of  the  clinical  type 
first  described  and  definitely  isolated  by  Rose,  who  con- 
tributed a  masterly  study  of  the  type  to  Pitha  and 
Billroth's  manual. 

SPHLANCNIC   TETANUS 

Sphlancnic  tetanus  may  be  regarded  as  a  partial  form 
of  tetanus  in  this  sense,  that  death  usually  occurs  before 
the  contractions  are  generalised. 

It  is  characterised  essentially  by  the  involvement 
of  the  muscles  of  deglutition  and  respiration,  which 
explains  the  intensity  of  the  dysphagia  observed  (a 
symptom  which  at  the  outset  might  lead  us  to  suppose 
that  we  had  to  deal  with  a  severe  angina),  by  the  in- 
tensity of  the  hydrophobia,  and  the  crises  of  suffoca- 
tion due  to  spasms  of  the  glottis  and  of  other  muscles 
of  the  respiratory  system.  The  dyspnoea  is  very 
marked,  and  the  asphyxial  phenomena  rapidly  be- 
come menacing. 

From  these  indications  it  will  be  understood  that  the 
forms  of  non-paralytic  cephalic  tetanus  which  may.  or 
may  not  be  accompanied  by  accentuated  dysphagia  or 
hydrophobia  are  to  be  regarded  as  coming  under  the 
heading  of  sphlancnic  tetanus. 

The  contractions  of  the  muscles  of  deglutition  and 
respiration  are  accompanied  and  sometimes  preceded 


KNOWN  ATYPJCAL  FOBMS  OF  TETANUS     709 

by  a  short  interval  of  trismus  and  stiffness  of  the  neck. 
This  is,  in  short,  a  form  of  partial  atjrpical  tetanus, 
localised  in  the  muscles  of  deglutition  and  respiration, 
and  the  muscles  of  the  head  and  neck. 

The  prognosis  is  grave,  and  almost  always  fatal. 

The  development  is  very  rapid,  and  death  occurs 
within  twenty-four  to  forty-eight  hours. 

This  form  of  tetanus  usually  follows  a  visceral  in- 
fection. 

Its  period  of  incubation  is  usually  long :  eight  or  ten 
days,  or  sometimes  more. 

CEPHALIC    TETANUS 
Cephalic  Tetanus  without  Paralysis 

Certain  writers  have  seen  fit,  wrongly,  as  we  think,  to 
multiply  the  forms  of  cephalic  tetanus,  basing  their 
classification  either  on  the  development  of  the  disease, 
or  on  its  degree  of  severity,  or  on  the  group  of  muscles 
affected  by  the  contractions.  Thus  acute,  chronic, 
continuous,  remittent,  pyretic,  apyretic,  analgesic, 
hyperalgesic,  ocular,  cervical,  masseteric,  generalised, 
localised,  dysphagic,  hydrophobic,  cesophageal,  and 
other  forms  have  been  described.  It  must,  however,  be 
recognised,  if  the  numerous  observations  of  cephalic 
tetanus  be  analysed,  that  clinical  varieties  exist  which 
are  plainly  defined  not  only  by  the  objective  indica- 
tions, but  also  by  the  progress  of  the  disease,  and  by 
the  prognosis.  It  is  therefore  impossible,  save  at  the 
cost  of  lucidity,  to  include  in  the  same  description  the 
true  hydrophobic  tetanus  with  its  alarming  paroxysms 
of  dysphagia  and  respiratory  troubles,  provoked  by  the 
mere  sight  of  a  glass  of  water,  and  without  any  paralytic 
phenomena,  and  the  varieties  of  tetanus  with  facial 


no       THE  ABNORMAL  FOBMS  OF  TETANUS 

paralysis   or   paralysis  of  the  motor  nerves   of   the 
eye. 

We  shall  therefore  describe,  under  the  head  of  the 
non-paralytic  forms  of  cephalic  tetanus,  in  addition 
to  the  simple  cephalic  variety,  characterised  only  by 
trismus  and  contractions  of  the  muscles  of  the  face 
and  neck,  the  dysphagic  types,  which  may  vary 
from  a  simple  difficulty  of  deglutition  to  hydro- 
phobia. 

1.  Simple  Cephalic  Tetanus. — In  this  rare  form  of  the 
disease  the  infection  is  confined  to  the  cephalic  region, 
as  a  result,  most  frequently,  of  a  wound  in  the  head. 
It  is  accompanied  only  by  unilateral  or  bilateral  tris- 
mus, or  by  contractions  of  certain  muscles  of  the  facial 
or  even  of  the  cervical  region.  But  in  this  type-  there 
are  never  dysphagic  or  paralytic  symptoms. 

2.  Cephalic  Tetanus  of  the  Dysphagic  Type.— Eliminating 
those  cases  in  which  there  is  simultaneously  dysphagia 
and  facial  paralysis,  we  may  clinically  define  two  types, 
which  are  sometimes,  however,  combined.    These  are : 

The  purely  dysphagic  form. 

The  hydrophobic  form. 

(a)  Dysphagic  Form. — Although  this  variety  differs 
definitely  from  the  hydrophobic  form  in  highly  accentu- 
ated cases,  this  is  no  longer  the  fact  in  cases  of  generalised 
tetanus.  In  such  cases  the  respiratory  symptoms 
make  their  appearance,  and  hydrophobia  becomes  the 
second  stage  of  the  infection.  Insensibly  the  disease 
passes  from  the  dysphagic  to  the  hydrophobic  variety. 

However  this  may  be,  this  form  is  characterised  by 
a  pharyngeal  spasm  which  precedes  the  trismus,  or  is 
associated  with  it.  The  trismus,  at  the  outset,  is  uni- 
lateral.   The  patient  is  sensible  of  pain  and  tension  on 


KNOWN  ATYPICAL  FORMS  OF  TETANUS      711 

one  side  of  the  jaw,  the  side  corresponding  to  the  wound. 
This  tension  presently  becomes  a  continuous  contrac- 
tion, with  convulsive  paroxysms.  The  trismus  remains 
thus  unilateral  for  a  variable  period,  usually  four  to  five 
days  ;  but  as  a  rule,  when  the  patient  seeks  advice,  the 
indications  have  become  threatening  and  the  trismus 
is  complete. 

The  trismus  is  almost  invariably  accompanied  by 
cervical  opisthotonos.  This  may  be  present  in  any 
degree,  from  a  mere  stiffness  of  the  neck  to  the  retro- 
version of  the  head.  It  makes  its  appearance  shortly 
after  the  trismus.  Paroxysms  of  the  affected  muscles 
may  be  aroused  by  the  slightest  excitation,  such  as  touch- 
ing the  wound  (Charvot),  but  their  most  frequent  cause 
is  the  voluntary  or  spontaneous  separation  of  the  jaws. 

The  pharyngeal  spasm  causes  more  or  less  accentuated 
dysphagic  disorders,  which  attain  their  maximum  of 
intensity  in  the  hydrophobic  form.  The  patient  can 
swallow  no  food  ;  and  the  least  absorption  of  liquid 
sets  up  painful  spasms  of  the  pharynx. 

Generally  speaking,  however,  the  disorders  of  deglu- 
tition are,  more  often  than  not,  of  no  great  severity. 

Apyrexia  is  the  rule,  at  all  events  at  the  outset.  The 
temperature  will  rarely  exceed  100 •4°  F. 

Lastly,  in  addition  to  the  cardinal  symptoms, 
dysphagia  and  contraction  of  the  muscles  of  the  neck, 
we  sometimes  observe  an  intense  dyspnoea,  which  con- 
tributes to  the  seriousness  of  the  prognosis  of  this  variety 
of  atypical  tetanus, 

(b)  Hydrophobic  Form. — This  is  a  very  rare  and  ex- 
ceptional form,  and  Reclus,  on  studying  all  the  observa- 
tions of  cephalic  tetanus,  discovered  only  two  in  which 
a  true  hydrophobia  was  present. 

In  addition  to  the  phenomena  of  dysphagia,  and  the 


712         THE  ABNORMAL  FORMS  OF  TETANUS 

muscular  contractions,  there  are  alarming  convulsions, 
provoked,  in  the  majority  of  cases,  either  by  touching 
the  pharynx,  by  a  movement  of  deglutition,  or  even  by 
the  mere  sight  of  a  liquid,  or  the  utterance  in  the 
patient's  presence  of  a  phrase  or  word  having  reference 
to  drinking. 

These  paroxysms  manifest  themselves  by  violent  con- 
vulsive spasms,  the  initial  seat  of  which  is  often  the 
wound,  with  irradiation  into  the  muscles  of  the  face 
(masseteric  or  other),  the  neck,  and  the  pharynx,  occa- 
sionally attaining  even  the  diaphragm ;  when  con- 
tractions of  the  respiratory  muscles  occur,  with  dyspnoea 
and  asphyxial  phenomena. 

Moreover,  generalisation  of  the  tetanus  is  frequent  in 
this  form,  and  the  prognosis  is  almost  invariably  fatal. 
Even  in  the  absence  of  generalisation  the  asphyxial 
phenomena  and  inanition  may  determine  the  fatal 
issue  of  the  case. 

Cephalic  Tetanus  with  Facial  Paralysis 

This  form  of  tetanus,  described  by  Poan  de  Sapin- 
court  as  the  facial  form  of  the  disease,  had  already 
been  remarked  by  Rose.  It  is  the  most  frequent  form, 
and  we  therefore  propose  to  study  it  at  greater  length 
than  the  others,  basing  our  remarks  on  the  highly 
interesting  and  fully  documented  thesis  of  Poan  de 
Sapincourt.  This  variety  arises  from  one  cause  only  : 
a  wound  in  the  face  or  the  neighbourhood  of  the  face. 
It  is  characterised  by  : 

1.  Contractions  which  usually  commence  in  the 
masticatory  muscles  of  the  wounded  side  (unilateral 
trismus),  often  invading  the  other  side,  and  the  muscula- 
ture of  the  neck.     They  may  become  generalised. 


KNOWJ^  ATYPICAL  FORMS  OF  TETANUS        713 

2.  Disorders  of  deglutition,  of  much  less  importance 
than  in  the  preceding  forms. 

3.  A  facial  paralysis,  almost  always  localised  on  the 
side  of  the  wound  (facial  hemiplegia),  or,  when  the 
wound  is  situated  on  the  median  line,  a  paralysis  of 
both  sides  (facial  diplegia). 

History 

This  form  of  tetanus  has  been  known  for  some  forty 
years,  and  was  for  the  first  time  described  by  Rose,  in 
1872.  In  the  two  observations  recorded  by  this  writer 
the  tetanic  contractions  resulted  from  a  wound  of  the 
face ;  and  in  both  patients  Rose  was  struck  by  the 
appearance  of  a  muscular  paralysis  of  that  side  of 
the  face  on  which  the  wound  was  situated. 

He  described  the  clinical  aspect  of  the  malady,  and 
carefully  studied  the  three  cardinal  symptoms : 

1.  Wound  in  the  region  of  the  cranial  nerves. 

2.  Appearance  of  facial  paralysis,  most  frequently 
on  the  injured  side. 

3.  Tetanic  contractions  extending  from  the  masseter 
to  all  the  facial  muscles,  the  muscles  of  the  neck,  and 
the  muscles  of  the  pharynx  and  the  oesophagus. 

Numerous  observations  have  been  recorded  since  the 
date  of  this  first  essay,  and  in  1888  Villar  summed  up 
the  whole  question  in  the  course  of  a  general  survey. 

Two  years  later,  in  1890,  appeared  the  thesis  of  Dr 
Albert  (of  Lyons)  ;  following  which  fresh  observations 
were  published,  and  Janin,  in  his  thesis  (1892),  referring 
to  two  personal  observations,  returned  to  the  subject, 
dividing  tetanus,  according  to  the  predominant  localisa- 
tion of  the  tetanic  toxin  in  the  nervous  centres,  into 
medullary   tetanus   (generalised   tetanus)   and  bulbar 


714    THE  ABNORMAL  FORMS  OF  TETANUS 

tetanus  (cephalic  tetanus  with  paralysis  of  the  facial 
muscles). 

In  the  same  year  Landouzy  cited  a  case  in  which 
there  was  only  an  appearance  of  facial  paralysis.  Reclus 
reported  some  personal  obseivations  in  1893,  and  in  the 
following  year  Houques  published  his  third  thesis,  en- 
titled Cepkalo- paralytic  Tetanus,  in  which  the  writer 
made  mention  of  no  fresh  facts,  but,  from  the  patho- 
genic point  of  view,  put  forward  a  theory  of  indirect 
origin.  He  admitted  an  original  lesion  by  contusion" 
of  the  terminal  branches  of  the  trigeminus  against  a  re- 
sisting plane  (osseous  or  external),  the  tetanic  infection 
being  said  to  invade  the  facial  nerve,  after  first  invading 
the  bulb,  in  which  the  facial  and  masseteric  nuclei  are 
adjacent.  Observation  followed  observation,  and  in 
1896  appeared  the  last  thesis  of  Le  Dard,  which  dealt 
particularly  with  facial  paralysis  in  tetanus. 

Finally,  we  may  mention  the  observations  of  Crouzon, 
Bourgeois,  and  Lortat- Jacob,  the  latter  inspiring  the 
work  of  Poan  de  Sapincourt  (1904)  ;  and  then  the  case 
observed  by  Binet  and  Trenel,  in  connection  with  which 
these  writers  briefly  summarised  the  question  of  the 
cephalic  forms  of  tetanus. 

Etiology ,  Frequency,  Age,  and  Sex 

Cephalic  tetanus  is  a  rare  affection,  whose  general 
etiology  is  that  of  the  classical  tetanus. 

It  must  be  remembered  that  this  facial  form  of 
tetanus  never  occurs  except  as  the  result  of  a  wound 
of  the  face,  whether  external  or  internal,  in  the  reaion 
innervated  by  the  facial  nerv  e.  This  feature,  according 
to  Poan  de  Sapincourt,  is  pathognomic. 

In  considering  the  special  etiology  of  this  form  of  the 


KNOWN  ATYFICAL  FORMS  OF  TETANUS      715 

disease  we  must  again  note  the  connection  between  the 
facial  paralysis  and  the  position  of  the  wound,  since  in 
the  majority  of  cases  the  facial  hemiplegia  is  found  on 
the  side  of  the  wound  by  which  the  infection  has  entered. 
And,  when  the  wound  is  median,  there  is  facial  diplegia. 

As  in  the  classical  tetanus,  men  appear  to  be  more 
exposed  to  the  disease  than  women.  Age  appears  to 
exert  a  certain  influence,  for  this  atypical  form  of  the 
disease  has  been  observed  more  particularly  in  youth 
and  maturity,  although  it  has  been  encountered  at  all 
ages. 

We  shall  not  further  insist  on  the  role  of  the  seasons, 
or  of  professional  factors,  in  the  etiology  of  this  form, 
for  all  that  might  be  said  would  apply  with  equal  force 
to  the  classic  forms  of  tetanus. 

Clinical  Survey 

Insidious  in  its  onset,  rather  tardy  in  establishing 
itself,  treacherous  in  its  progress,  and,  owing  to  its 
complications,  involving  a  slow  recovery  or  a  somewhat 
speedy  death — such,  in  a  few  words,  are  the  general 
characteristics  of  the  facial  form  of  the  tetanic  infection 
(Poan  de  Sapincourt). 

Following  a  wound  in  the  face,  insignificant  in  the 
majority  of  cases,  and  caused  by  a  fall  on  a  stony  road, 
or  the  bite  of  a  horse,  or  a  bullet  wound,  or  even  by  a 
neglected  ulceration,  and  after  a  period  varying  from 
two  to  twenty-two  days  (on  an  average,  eight  days) 
during  which  there  are  no  premonitory  symptoms 
(neither  fever,  nor  fatigue,  nor  shivering,  nor  pains,  nor 
insomnia)  announcing  the  onset  of  the  malady,  the 
patient  awakes  one  morning  with  a  stiffness  in  one  or 
both  jaws.     Sometimes  there  is  pain  at  the  same  time. 


716     THE  ABNORMAL  FORMS  OF  TETANUS 

Difficulty  of  mastication  and  of  speech  follow. 

Presently  this  stiffness  and  constraint  give  way  to 
muscular  contraction  and  spasms,  and  the  character- 
istic trismus  makes  its  appearance.  At  this  period  the 
wound  in  which  the  toxins  are  produced  is  usually 
cicatrised,  and  the  patient,  no  longer  regarding  it  as 
of  any  importance,  calls  the  attention  of  the  physician 
only  to  the  pain  and  the  trismus. 

These  symptoms  then  increase  in  intensity,  and  the 
patient  is  obliged  to  take  to  his  bed.  The  opposite  side 
of  the  face  may  become  contracted,  and  the  wounded 
side  is  completely  paralysed.  We  have  to  deal  with  a 
typical  facial  paralysis,  the  mouth  crooked  and  droop- 
ing, allowing  the  saliva  to  trickle  out ;  the  labial  furrow 
is  effaced,  the  cheeks  are  flaccid,  wrinkles  have  dis- 
appeared, and  the  eye  is  widely  opened. 

Contracture  and  paralysis,  moreover,  are  frequently 
associated,  and  the  patient's  face  assumes  the  hideous 
mask  described  as  the  risus  sardonicus. 

The  paralysis  alarms  the  patient,  while  his  attention 
is  centred  upon  the  persistence  and  increase  of  the 
pains,  which  become  unendurable,  the  closing  of  the 
jaws,  which  become  more  and  more  firmly  shut, 
the  insomnia,  and  the  prospect  of  no  longer  being  able 
to  take  food.  Indeed,  the  absoi*ption  of  liquids  is 
already  difficult,  and  gives  rise  not  only  to  pain  but  to 
paroxysmal  contractions.  For  this  reason  the  patient, 
when  the  paroxysm  is  over,  fearing  its  return,  finally 
refuses  all  nourishment. 

The  clinical  picture  is  sometimes  completed  by 
dysphagia  ;  at  each  attempt  at  deglutition  the  con- 
tractions occur,  and  may  even  lead  to  an  actual 
hydrophobia. 

These  local  symptoms  having  fully  developed,  the 


KNOWN  ATYPICAL  FORMS  OF  TETANUS   717 

malady  progresses  slowly  in  the  direction  of  recovery, 
or  else  the  contractions  may  become  more  or  less 
rapidly  generalised,  the  local  atypical  malady  hence- 
forth assuming  the  aspect  of  the  classic,  generalised 
form  of  tetanus,  with  its  serious  prognosis. 

Such,  in  its  most  frequent  form,  and  briefly  described, 
is  the  clinical  aspect  of  cephalic  tetanus  with  facial 
paralysis.  We  propose  now  to  insist  yet  further  upon 
the  individual  signs  of  this  type,  in  order  that  we  may 
clearly  demonstrate  its  characteristics. 

Individual  Signs  of  Cephalic  Tetanus  with 
Facial  Paralysis 

1.  Situation  of  the  Wound. — ^We  think  it  as  well  again 
to  call  attention  to  the  fact  that  this  facial  form  of 
cephalic  tetanus  has  never  been  observed  save  as  follow- 
ing upon  a  wound  of  the  head,  though,  as  Poan  de 
Sapincourt  has  justly  remarked,  this  does  not  mean 
that  every  wound  in  the  head  infected  by  Nicolaier's 
bacillus  will  result  in  facial  paralysis. 

Moreover,  in  all  the  observations  published  one  is 
struck  by  the  far  from  extensive  and  occasionally 
superficial  localisation  of  the  wounds  in  which  the 
tetanic  infection  has  originated. 

They  are  situated  more  particularly  on  the  upper  or 
lower  border  of  the  orbit,  the  superciliary  ridge,  the 
root  of  the  nose,  the  malar  region,  or  the  inferior  portion 
of  the  frontal  region.  In  one  single  case  the  wound 
was  occipital.  In  short,  the  traumatic  lesions  are 
situated  in  the  area  innervated  by  the  two  branches 
of  the  facial  nerve,  and  above  all  by  the  superior 
division  of  the  facial  nerve,  and  Villar  has  given  to 
this  area  the  name  of  the  orbito-naso-temporo-malar 


718  THE  ABNORMAL  FORMS  OF  TETANUS 

region,    thus   summarising   the   common  localisations 
of  the  wounds  which  give  rise  to  cephalic  tetanus. 

2.  Incubation.  —  The  period  of  incubation  is  not 
accompanied  by  any  indication  which  leads  us  to 
suspect  probability  of  local  tetanus.  The  wound,  as 
a  rule,  becomes  cicatrised  in  a  normal  manner,  unless, 
as  is  often  the  case,  it  contains  some  foreign  body. 
This  phase  lasts,  on  an  average,  nine  days,  but  it  may 
be  shorter. 

The  first  symptoms  have  been  known  to  appear  at 
the  end  of  two  days.  Sometimes  the  period  of  in- 
cubation is  longer ;  it  may  be  as  long  as  twenty-two 
days. 

During  the  period  of  incubation  slight  pain  in  the 
neighbourhood  of  the  wound  and  in  the  temporo- 
maxillary  articulation  may  be  sometimes  noted.  Once 
the  period  of  incubation  is  over  the  characteristic  signs 
make  their  appearance  with  some  degree  of  suddenness. 

3.  Trismus. — -This  symptom  is  almost  always  the 
first  to  appear.  Sometimes  isolated,  sometimes  associ- 
ated with  facial  paralysis,  it  is  occasionally  accompanied 
by  dysphagia  or  dyspnoea. 

The  trismus  is  confined,  at  the  outset,  to  a  transient 
discomfort  in  the  jaw.  Pain  is  felt  upon  pressure  in 
the  masseteric  region,  or  when  the  patient  attempts  to 
open  his  mouth.  The  trismus  is  at  this  stage  uni- 
lateral, and  is  situated  on  the  same  side  as  the  wound, 
but  it  very  soon  becomes  bilateral,  although  it  remains 
predominant  on  the  wounded  side. 

There  is  nothing  surprising  in  this  initial  localisation, 
for  we  have  learned  experimentally  that  the  contracture 
always  makes  its  first  appearance  in  the  muscles  neigh- 
bouring upon  the  place  of  inoculation. 


KNOWN  ATYPICAL  FORMS  OF  TETANUS      719 

4.  Muscular  Contractions. — These  rarely  appear  before 
the  trismus,  or  simultaneously  with  it.  They  are  usually 
observed  afterwards,  and  may  invade  all  the  muscles  of 
the  face,  and  neck. 

They  may  be  situated  on  the  same  side  as  the  facial 
paralysis,  or  on  the  opposite  side,  or  even  on  both  sides 
(in  the  case  of  a  median  wound),  but  in  general  they 
commence  on  the  paralysed  side. 

The  contractions  are  variable  in  degree  ;  they  may 
amount  to  a  mere  stiffness,  or  in  very  marked  cases 
they  may  cause  the  immobilisation  of  the  head  in  an 
unnatural  attitude,  giving  rise  to  cervical  opisthonotos. 

As  in  the  classical  form  of  tetanus,  these  contractions 
are  tonic,  but  spasmodic  paroxysms  may  be  aroused  by 
the  slightest  excitation  (touching  the  wound,  or  move- 
ments of  mastication  or  deglutition). 

We  can  understand  the  difficulties  of  the  clinicians 
when  confronted  by  a  lesion  of  the  facial  nerve  producing 
paralysis  and  contraction  in  ihe  same  muscles. 

Nevertheless,  it  is  possible  to  explain  this  pheno- 
menon :  for  the  paralysis  and  the  contractions  do  not 
act  in  the  same  direction,  nor  in  the  same  nervous 
territories.  As  Pechoutre  contends,  contraction  is  a 
phenomenon  which  has  a  central  point  of  departure, 
while  paralysis,  at  least  in  the  beginning,  results  from 
a  change  in  the  peripheral  nerve  branches  neighbouring 
upon  the  wound,  due  to  the  tetanic  toxin  (Roux, 
Borel,  Marie,  Morax). 

These  two  symptoms  have  thus  been  explained  by 
Guiffre,  and  his  explanation  is  very  probable:  "The 
contractions  of  the  facial  muscles  affected  by  paralysis," 
he  says,  "  do  not  in  this  case  differ  in  any  way  from  the 
ordinary  tetanic  contractions,  except  that  they  occur 
in  muscles  already  paralysed.     To  explain  this  fact  we 


720     THE  ABNORMAL  FORMS  OF  TETANUS 

may  suppose  that  the  voluntary  impulse  is  not  suffi- 
ciently transmitted  by  the  affected  nerves  to  the  muscles 
of  the  periphery,  while  the  tetanic  toxin,  on  the  contrary, 
is  sufficiently  powerful  to  sur-excite  the  nuclei  of  the 
facial  nerve,  and  to  cause  contractions  in  muscles  which 
no  longer  react  to  the  voluntary  impulses." 

Guiffre  goes  so  far  as  to  compare  tetanus  to  electrical 
stimulation,  which  is  able  to  cause  contractions  of, 
paralysed  muscles. 

In  those  cases  in  which  there  are  only  paralytic 
phenomena,  it  must  be  supposed  that  the  tetanus  toxin 
has  remained  localised  at  the  periphery,  and  has  not 
reached  the  nucleus  of  the  facial  nerve,  or  has  not 
affected  it  sufficiently  to  excite  the  paralysed  rami. 

We  have  also  mentio'ned,  and  this  fact  is  recorded  in 
a  score  of  observations,  and  particularly  in  those  of 
Charvot,  Villar,  and  Reclus,  that  the  contractions  may 
occur  on  the  opposite  side  to  that  affected  by  the  facial 
paralysis.  The  result  is  a  very  remarkable  facial 
asymmetry,  which  gives  rise  to  the  grimace  known  as  the 
risus  sardonicus,  when  the  paralysed  side  assumes  an 
expression  of  profound  apathy,  while  the  contracted  side 
wears  an  expression  of  appalling  fury  (Poan  de  Sapln- 
court).  This  characteristic  expression  is  peculiar  to  the 
tetanic  infection. 

The  contractions  may  also  become  generalised  ; 
cervical  opisthotonos  often  accompanies  cephalic 
tetanus.  But  if  the  infection  gains  ground  the  contrac- 
tions may  affect  the  trapezius,  and  the  muscles  of  the 
back,  abdomen,  and  limbs. 

This  extension  is  serious,  above  all  when  the  pharynx, 
oesophagus,  and  diaphragm  are  in  turn  affected,  as 
dysphagia  may  be  caused,  and  consequently  inanition 
and  asphyxial  symptoms. 


KNOWN  ATYPICAL  FORMS  OF  TETANUS    721 

5.  Facial  Paralysis. — Complete  or  incomplete,  facial 
paralysis  is  never  absent  in  this  atypical  form,  although 
paralysis  is  extremely  rare  in  the  classic  form  of  tetanus. 

Commencement. — Facial  paralysis  is  not  always  the 
first  sign  of  the  malady,  and  we  have  seen  that  trismus 
may  precede  it  or  co-exist  with  it.  Nevertheless,  it  is 
an  early  symptom,  which  at  once  attracts  the  attention 
of  those  about  the  patient,  and  of  the  physician. 

It  is  most  frequent  between  the  seventh  and  the 
twelfth  day,  but  may  appear,  as  we  have  remarked,  at 
any  time  between  the  second  and  the  twenty-fourth 
day  of  the  disease.  In  cases  likely  to  recover  it  tends 
to  appear  late,  while  in  fatal  cases  it  makes  its  appear- 
ance between  the  second  and  eighth  days.  Its  early 
or  late  appearance  may,  therefore,  be  of  prognostic 
significance. 

Lastly,  there  is  no  fixed  relation  between  its  appear- 
ance and  that  of  the  trismus  ;  sometimes  paralysis 
follows  the  latter ;  sometimes  it  appears  simultaneously ; 
sometimes  it  precedes  it. 

Situation. — As  a  rule  the  facial  paralysis  is  observed 
on  the  same  side  as  the  wound  in  which  the  tetanic 
toxin  is  produced,  and  if  the  wound  is  median,  there  is 
usually  facial  diplegia,  either  as  an  initial  or  as  a  late 
symptom. 

Clinical  Characters. — The  facial  paralysis  occurring 
in  cephalic  tetanus  recalls  in  every  respect  the  ordinary 
paralysis  of  peripheral  origin.  Nevertheless,  when  the 
tetanic  toxin  has  invaded  the  ner\^ous  centres,  when 
the  intraosseous  portion  of  the  facial  nerve  is  injured, 
the  paralysis  presents  the  characteristics  of  a  central 
paralysis  of  bulbar  origin. 

In  the  super-acute  forms,  moreover,  it  may  resemble 
bulbar  paralysis  from  the  beginning,  and  in  this  case 


723    TEE  ABNORMAL  FORMS  OF  TETANUS 

there   is  nothing  surprising  in  the  development  of  a 
paralysis  of  the  side  opposite  to  the  wound. 

This  is  a  paralysis  of  a  toxi-infectious  nature,  com- 
parable to  the  paralysis  of  diphtheria. 

(a)  The   type  most  frequently  observed  is  cephalic 
tetanus  with  complete  peripheral  facial  paralysis.     Into 
this  group  fall  those  cases  in  which  the  paralysis  affects 
one  half  of  the  face,  and  involves  all  the  muscles  in- 
nervated by  the  two  branches  of  the  peripheral  facial 
nerve,  the  motor  nerves  of  the  muscles  of  the  ossicles 
or  the  chorda  tympani  never  being  affected.     Such  cases 
present   the   type   of    the   ordinary   peripheral    facial 
paralysis.     In  all  the  observations  of  these  cases  we  find 
the  signs  of  this  affection  are  more  or  less  fully  recorded. 
There  is  exaggeration  of  the  facial  asymmetry  by  every 
movement,  the  disappearance  of  the  naso-labial  furrow 
on  the  affected  side,  and  on  the  sound  side  there  is 
incomplete  closure  of  the  lips,  with  dripping  of  saliva, 
and  the  nose  is  diverted  to  the  sound  side.     The  ala  nasi 
on  the  paralysed  side  is  no  longer  raised  each  time  a 
fairly  deep  breath   is  taken,  but,  on  the  contrary,  is 
flattened,  and  the  nostril  contracts,  w^hile  the  eye  on 
the  affected  side  can  no  longer  be  closed  ;    sometimes 
this  gives  rise   to  epiphora  and   conjunctivitis.     The 
wrinkles  of  the  forehead  are  effaced  ;     the  superciliary 
muscles  are   immobile  ;    and  the  face  is  strange  and 
expressionless. 

Sweating  on  the  affected  side  is  found  to  be  affected 
on  application  of  the  pilocarpin  test. 

In  this  complete  form  hearing  and  taste  are  un- 
affected, the  soft  palate  is  normal,  and  the  uvula  is  not 
drawn  to  one  side. 

{b)  In  certain  cases  the  superior  facial  nerve  is  un- 
affected, and  consequently  the  superior  facial  muscles 


KKOM^y  ATYFICAL  FORMS  OF  TETANUS     723 

are  not  involved.     The  eye  may  be  closed,  and  the  lines 
and  wrinkles  of  the  frontal  region  are  not  obliterated. 

In  this  variety  we  have  tc  deal  with  an  incomplete 
facial  paralysis  involving  the  lower  facial  muscles,  and 
this  in  turn  may  be  divided  into  two  categories,  accord- 
ingl}  as  the  middle  rami  only  or  the  inferior  rami  only 
of  the  facial  nerve  are  affected.  It  is  thus  possible  to 
define  a  middle  inferior  type  and  a  pure  inferior  type,  a 
good  example  of  which  is  described  by  Crossonard.  In 
this  case,  a  wound  of  the  lower  lip,  only  the  triangularis 
menti  muscle  was  affected. 

(c)  Much  more  rarely,  and  quite  as  an  exception,  the 
toxin  may  spare  the  wferior  facial  region  ;  we  then  have 
cephalic  tetanus  of  the  superior  facial  type.  The  eye  is 
open,  and  the  wrinkles  of  the  forehead  are  effaced,  but 
the  muscles  of  the  nose,  lips,  and  chin  are  unaffected. 

(d)  Lastly,  there  are  cases  of  total  facial  paralysis 
no  longer  peripheral, » but  involving  the  muscles  of  the 
ossicles  and  of  the  chorda  tympani.  In  these  cases  there 
is  a  toxic  invasion  of  the  petrosal  portion  of  the  facial 
nerve,  which  is  manifested  by  disturbance  of  the  hearing, 
taste,  and  smell.  The  observation  recorded  in  1902  by 
Lortat- Jacob  is  very  interesting  and  instructive  in  this 
connection  ;  the  patient,  who  was  ten  years  of  age, 
had  received  a  wound  on  the  outer  portion  of  the  orbital 
rim  of  the  left  malar.  On  the  eighth  day  cephalic 
tetanus  made  its  appearance,  with  complete  facial 
paralysis  and  disturbances  of  smell,  taste,  and  hearing. 
Odours  could  not  be  perceived  by  the  left  nostril  (the 
paralysed  side).  Taste  was  abolished  on  the  same  side ; 
ahtipyrine,  sulphate  of  quinine,  and  sugar  (syrup)  failed 
to  produce  any  plainly  different  sensations,  while  taste 
and  smell  on  the  right-hand  side  remained  unaffected. 

A  watch  was  heard  at  a  distance  of  30  centimetres 


724    THE  ABNORMAL  FORMS  OF  TETANUS 

on  the  right  side,  and  at  a  distance  of  more  than  40 
centimetres  on  the  left  side,  indicating  some  degree  of 
hyperacusis  on  the  injured  side. 

This  fortunately  rare  form  is  far  more  serious  than 
the  preceding  types  ;  it  indicates,  as  a  rule,  a  tendency 
to  generalisation ;  moreover,  the  paralysis  itself  is 
less  readily  recovered  from. 

Development  and  Prognosis 

The  facial  paralysis  usually  remains  localised  during 
the  whole  term  of  the  malady.  It  improves  and  tends 
to  disappear  simultaneously  with  the  trismus,  some- 
times even  before  the  latter  (Oliva). 

In  certain  cases,  however,  the  paralysis  has  dis- 
appeared only  when  convalescence  was  reached,  and 
it  has  even  been  known  to  persist  after  recovery  from 
active  tetanus. 

As  a  rule,  when  the  patient  has  recovered  from  tetanus 
the  paralysis  has  disappeared.  Its  prognosis  is,  there- 
fore, good,  especially  when  its  appearance  is  delayed. 

Diagnosis  of  Facial  Paralysis. — ^When  the  facial 
paralysis  is  the  first  sign  of  tetanus  it  is  difficult  to 
recognise  its  etiology,  and  the  causes  of  error  are 
numerous. 

Paralysis  of  central  origin  is  quickly  eliminated  ; 
with  this  there  are  other  symptoms  of  a  serious  lesion. 

Similarly,  hystero-traumatic  functional  disorder,  as 
the  result  of  a  wound  in  the  head,  might  possibly 
produce  somewhat  similar  symptoms ;  but  in  this  case 
the  mode  of  onset,  and  the  fact  that  the  lower  face  is 
never  exclusively  affected,  and  above  all  the  condition 
of  paresis  rather  than  paralysis,  makes  it  totally  unlike 
peripheral  facial  paralysis. 


KNOWN  ATYPICAL  FORMS  OF  TETANUS     725 

We  may  inquire,  too,  whether  the  paralysis  may  not 
be  caused  by  a  direct  traimiatic  lesion  of  the  facial 
nerve  ;  we  may  have  to  do  with  either  a  peripheral 
lesion  of  the  nerve,  a  mistake  easily  made,  considering 
the  usual  position  of  the  wound,  or  a  lesion  of  the  intra- 
petrous  portion  due  to  fracture  of  the  petrosa.  The 
symptoms  peculiar  to  this  affection  will  rapidly  establish 
the  diagnosis. 

Lastly,  the  physician  may  suspect  a  case  of  Bell's 
palsy,  or  disease  of  the  middle  ear. 

Such  a  case  may  be  accompanied  by  temporo- 
maxillary  arthritis  and  unilateral  trismus,  which 
render  the  diagnosis  still  more  difficult.  An  examina- 
tion of  the  auditory  passage  should  always  be  made. 

Pathogenesis, — ^Basing  our  remarks  upon  experimental 
data,  the  facial  paralysis  may  be  conceived  as  follows : — • 
After  a  superficial  infected  wound  in  the  territory  of 
innervation  served  by  the  facial  nerve,  there  is  an  ab- 
sorption of  toxin  by  the  peripheral  nerve  branches  in 
the  neighbourhood  of  the  wound,  the  toxin  gradually 
reaching  to  the  central  neuron  and  the  medulla,  travel- 
ling solely  along  the  nerves. 

The  infection  may  be  localised,  or  may,  on  the  con- 
trary, spread  along  the  cerebro-spinal  axis.  It  follows 
that  we  may  observe  different  forms  of  paralysis 
according  to  the  degree  of  infection. 

6.  Fever. — ^Most  writers  regard  apyrexia  as  one  of  the 
peculiar  and  constant  characteristics  of  cephalic  tetanus. 
There  is  frequently,  however,  a  slight  rise  of  temperature, 
and  fever  is  almost  always  encountered  when  there 
are  indications  pointing  to  the  invasion  of  the  tetanic 
infection — -that  is,  in  serious  cases.  In  the  absence  of 
such  a  rise  of  temperature  the  pulse  must  be  consulted- 


726    THE  ABNORMAL  FORMS  OF  TETANUS 

for  its  great  frequency  is  almost  the  rule  in  the  facial 
form  of  tetanus. 

Bacteriology. — In  some  cases  of  cephalic  tetanus  it 
has  been  possible  to  demonstrate  the  presence  of 
Nicolaier's  bacillus,  and  even  to  cultivate  it.  It  has 
even  been  possible  to  produce  an  experimental  tetanus 
with  local  contractions  (Lortat- Jacob).  But  in  the 
tissues  attacked  by  the  tetanic  toxin  no  discovery  has 
been  made  of  clearly  defined  lesions  such  as  would 
explain  the  intensity  and  the  gravity  of  the  clinical 
indications  observed. 

Development,  Duration,  Prognosis. — As  in  the  classical 
forms  of  tetanus,  the  development  may  be  acute  or 
sub-acute. 

In  two  cases  its  duration  did  not  exceed  three  days 
(two  deaths) ;  in  fifteen  cases  it  varied  from  five  to  ten 
days  (fourteen  deaths).  In  the  other  cases  the  tetanus 
was  prolonged  after  the  second  week  (one  death  and 
four  recoveries). 

The  prognosis  is  thus  to  a  certain  extent  dependent 
upon  the  progress  of  the  disease,  yet  a  case  which  by  its 
early  stages  and  its  duration  would  lead  us  to  expect 
rapid  recovery  may  suddenly  assume  an  acute  develop- 
ment and  end  fatally.  Similarly,  a  case  regarded  as 
mortal  may  terminate  favourably. 

The  prognosis  must  accordingly  always  be  reserved, 
whatever  the  course  of  development,  or  the  apparent 
benignity  or  gravity  of  the  symptoms,  and  although  the 
prognosis  is  much  less  gloomy  than  in  ordinary  tetanus. 

The  mortality  does  not  exceed  50  per  cent. 

Lastly,  there  are  certain  factors  which  may  darken 
the  prognosis. 

Apart  from  the  period  of  incubation,  the  progress  of 
the  malady,  the  degree  of  infection,  and  rapidity  of 


KNOWN  ATYPICAL  FORMS  OF  TETANUS    nil 

spread,  the  prognosis  is  also  dependent  upon  the  age 
of  the  individual,  and  his  powers  of  resistance,  and  on 
an  early  diagnosis,  which  will  permit  of  the  speedy- 
institution  of  a  curative  treatment. 

Diagnosis. — Once  typical  symptoms  have  appeared 
they  permit,  as  a  rule,  of  a  ready  diagnosis.  It  must 
not,  however,  be  supposed,  because  a  wound  in  the 
trigeminal  area  is  accompanied,  at  all  events  in  the  first 
place,  by  trismus  of  the  same  side,  and  by  facial  paralysis, 
that  there  is  no  room  for  hesitation  as  to  the  nature 
of  the  symptoms  observed.  Above  all  at  the  outset, 
when  the  three  chief  symptoms  are  not  complete,  certain 
affections  may  give  rise  to  confusion,  the  more  readily  in 
that  the  wound  may  be  cicatrised,  insignificant,  and 
occasionally  forgotten  by  the  patient,  while  the  trismus 
may  be  slight,  and  unilateral,  and  facial  paralysis  may 
be  late  in  appearing. 

The  tetanic  infection  may  be  imrecognised  when  the 
initial  sign  is  merely  a  pain  localised  on  one  side  of  the 
face,  or  even  a  unilateral  trismus.  A  direct  traumatism 
of  a  branch  of  the  facial  nerve,  the  cutting  of  a  wisdom- 
tooth,  hysteria,  dental  caries,  or  cold  may  provoke 
the  same  objective  manifestations. 

Similarly,  spasmodic  facial  neuralgia  (tic  douloureux) 
may  give  rise  to  analogous  pains  and  contractions. 
These  are  frequently  observed  in  certain  cases  of 
neuralgia  of  the  trigeminal  nerve.  As  a  rule,  there  is 
a  sudden  contraction  of  the  muscles  innervated  by  the 
facial  nerve  on  the  side  corresponding  to  the  pain.  This 
is,  however,  merely  a  motor  reflex  caused  by  the  sudden 
pain  experienced  by  the  patient. 

Lastly,  the  traumatic  spasms  described  by  Colles 
and  FoUin  are  differentiated  only  by  the  absence  of 
Nicola  ier's  bacillus. 


ns    THE  ABNORMAL  FORMS  OF  TETANUS 

It  is,  however,  probable  (and  we  shall  return  to  this 
point  when  examining  the  monoplegic  partial  forms  of 
tetanus)  that  in  many  of  the  cases  described  by  these 
writers  they  were  in  reality  confronted  by  atypical  and 
localised  forms  of  tetanus. 

However  this  may  be,  when  we  have  to  deal  with  a 
wound  in  the  face  which  may  have  been  contaminated 
by  the  soil,  or  by  dust,  or  which  contains  a  septic 
foreign  body,  and  is  accompanied  by  local  contracture, 
or  merely  by  facial  asymmetry,  the  possibility  of 
cephalic  tetanus  with  facial  paralysis  must  never  be 
overlooked.  In  the  absence  of  trismus  it  will  always 
be  necessary  to  investigate  the  case  thoroughly  from 
the  clinical  bacteriological  aspect  before  rejecting  the 
hypothesis  of  an  atypical  tetanic  infection.  By  careful 
investigation  we  may  sometimes  recognise  this  special 
form  of  tetanus  at  the  outset,  and  institute  a  treatment 
which  will  be  the  more  efficacious  as  it  is  more  promptly 
applied. 

This  serotherapeutic  and  symptomatic  treatment 
will  differ  in  no  respect  from  the  treatment  adopted  for 
other  forms  of  the  disease.  We  will  only  mention  that 
the  particular  localisation  of  the  infection  has  encour- 
aged certain  clinicians  to  administer  injections  of  anti- 
toxin near  the  place  of  inoculation,  and  for  this  purpose 
the  lax  cellular  tissue  of  the  cheek  offers  as  great  a 
facility  to  the  needle  as  the  skin  of  the  thigh  or  the 
abdomen.  Others  have  recommended  the  irrigation  of 
the  wound  with  antitetanic  serum ;  it  is  possible  that 
in  this  method,  if  the  serum  does  not  destroy  the 
toxin,  it  may  diminish  its  virulence  and  its  rapidity 
of  production. 

One  thing  at  least  is  certain,  and  we  cannot  lay  too 
much  stress  upon  it :    that  when  confronted  by  an 


KNOWN  ATYPICAL  FORMS  OF  TETANUS     729 

excoriation  or  a  wound  of  a  suspicious  character  on  the 
face  (however  slight  or  superficial  it  may  be)  we  ought 
always  to  administer  a  preventive  injection  of  anti- 
tetanic  serum,  which  should  be  repeated  a  week  later 
if  any  doubt  persists  as  to  the  possibility  of  tetanus, 
and  that  the  wounded  subject  will  thus  be  protected 
from  the  risk  of  a  delayed  infection. 

Cephalic  Tetanus  with  Ophthalmoplegia 

In  addition  to  facial  paralysis,  cephalic  tetanus  may 
be  accompanied  by  ophthalmoplegia,  and  Worms,  in 
his  thesis  on  the  subject,  has  particularly  examined 
this  form. 

History 

The  affection  of  the  ocular  muscles  in  cephalic 
tetanus  long  escaped  the  attention  of  medical  writers. 
Hippocrates,  Striimpel,  Larrey,  and-Harkness  had,  it 
is  true,  mentioned  the  occurrence  of  ocular  troubles 
during  tetanus,  but  they  did  not  attach  any  great 
importance  to  the  fact.  Only  in  1882  did  Wahl 
publish  the  first  observation  of  tetanic  ophthalmo- 
plegia. Four  years  later  Sereins  mentioned  a  case  of 
cephalic  tetanus  complicated  by  ptosis,  and  in  1890 
Rocliffe  described  a  further  case  accompanied  by  a 
double  ptosis  and  diplopia.  These  observations  were 
followed  by  those  of  Roberts  and  Williamson  in  1891, 
and  of  Marx  and  Caird  in  1893.  Then,  in  1894, 
Fromaget  published  an  interesting  memoir  in  the 
Archives  d'Ophtkalmologie,  dealing  with  the  ocular  mani- 
festations of  tetanus.  After  the  appearance  of  this 
memoir  numerous  observations  were  published,  and 
Worms,  in  1905,  in  his  thesis  upon  "  bulbo-paraly tic  " 


730  THE  ABNORMAL  FORMS  OF  TETANUS 

tetanus,  described  the  clinicai  appearance  of  the 
particular  atypical  form  which  we  are  about  to  re- 
capitulate here. 

Etiology 

As  in  the  other  forms,  the  cause  of  cephalic  tetanus 
with  ophthalmoplegia  is  the  infection  of  a  wound 
by  the  tetanus  bacillus,  and  we  may  repeat  here 
what  we  have  already  stated  in  connection  with  the 
preceding  form  as  to  the  influence  of  such  factors  as 
the  profession  of  the, subject  (carters,  gardeners,  farm 
labourers,  etc.,  being  particularly  liable  to  infection), 
the  nature  of  the  traumatism,  and  the  influence  of  the 
factors  of  age  and  sex  (adult  man). 

A  more  important  factor  is  the  position  of  the  wound, 
which  is,  in  the  majority  of  cases,  a  wound  of  the  head, 
situated  in  the  orbito-superciliary  region,  which,  on 
account  of  its  prominence,  is  frequently  exposed  to 
traumatisms. 

The  eyebrow  is  often  involved.  The  skin  of  this 
region,  on  account  of  its  anatomical  situation,  is  ex- 
posed to  the  type  of  contused  wounds  favourable  to  the 
development  of  Nicolaier's  bacillus. 

The  eyelids  are  sometimes  a  site  of  infection  when 
injured  by  cutting  or  stabbing  instruments. 

In  several  cases,  those  in  which  the  tetanic  ophthal- 
moplegia was  most  clearly  defined,  the  trauma  was  in 
the  eyeball. 

As  Worms  has  justly  remarked,  the  eye,  protected 
by  the  superciliary  arch,  and  backed  by  a  fatty  cushion, 
would  seem  as  though  bound  to  escape  tetanic  infec- 
tion. In  these  cases,  however,  the  wounds  were  not 
caused  by  falling  upon  the  face,  but  by  projectiles 
(bullets,  splinters  of  wood,  whip-lashes)  discharged  so 


KNOWN  ATYPICAL  FORMS  OF  TETANUS     731 

suddenly  that  the  sufferers  were  unable  to  protect  the 
eyes. 

It  must  not  be  supposed  that  tetanus  occur- 
ring under  such  conditions  is  always  complicated  by 
ophthalmoplegia.  The  cases  observed  by  Denuce  and 
Chrisolm  manifestly  prove  as  much. 

Lastly,  when  we  have  to  deal  simply  with  ptosis 
associated  with  paralysis  of  the  face  the  position  of  the 
wound  may  be  in  the  region  of  the  cheekbone,  the  nose, 
the  temporal  region,  or  even  in  the  mucous  membrane 
of  the  buccal  cavity. 

A  case  is  recorded  in  which  the  wound  was  in  the 
right  foot  (Zack). 

Clinical  History 

Initial  Symptoms. — The  ophthalmoplegia  may  on  oc- 
casion be  the  first  symptom  of  tetanus,  apart  from  any 
other  manifestation.  This  was  the  case  in  the  observa- 
tion published  by  Lepine  and  Sarvonat.  In  such  cases 
it  is  only  after  the  lapse  of  some  days  that  the  stiffness 
in  the  jaws  and  a  slight  amount  of  pain  make  their 
appearance.  The  patient  experiences  a  difficulty  in 
speaking,  and  very  soon  the  stiffness  passes  into  con- 
tractions and  spasms  of  characteristic  trismus. 

The  patient  is  then  obliged  to  take  to  his  bed,  and  the 
symptoms  become  aggravated.  The  face  becomes  con- 
tracted on  the  sound  side  and  paralysed  on  the  side 
of  the  lesion  {risus  sardonicus).  The  trismus  becomes 
more  and  more  intense  and  alimentation  impossible. 
The  muscular  phenomena  usually  extend  to  the  neck, 
the  trunk,  and  the  limbs,  especially  the  lower  limbs. 

During  this  development  the  ophthalmoplegia  per- 
sists, either  unchanged  or  with  certain  modifications. 


732     THE  ABNORMAL  FOFMS  OF  TETANUS 

One  muscle,  which  was  not  involved,  may  become  para- 
lysed ;  another,  which  was  completely  paralysed,  may 
begin  to  act  again  ;  the  strabismus  may  increase  or 
diminish  (Worms). 

If  the  ophthalmoplegia  is  localised  in  one  eye,  then 
toward  the  last  days  of  the  malady,  or  sometimes 
only  during  the  terminal  period,  the  sound  eye  is  also 
affected. 

Symptomatology.  —  The  ophthalmoplegia  in  the 
observation  published  by  Lepine  and  Sarvonat,  which 
we  have  already  described,  was  so  definite  that  we  may 
well  describe  it.  In  their  patient  paresis  of  all  the 
muscles  was  observed,  the  eyelid  falling  and  hiding  the 
greater  part  of  the  cornea,  and  the  patient,  who  had 
the  appearance  of  being  drowsy,  threw  the  head  back 
in  his  attempts  to  see  from  under  the  drooping  lid. 
The  forehead  was  wrinkled  and  the  eyebrow  lifted,  in 
order  to  supplement  the  insufficiency  of  the  levator 
palpebrge.  Examining  the  movements  of  the  eye,  it 
was  seen  to  be  fixed  in  one  position  ;  slight  movements 
outwards  only  were  observed,  the  right-hand  external 
muscle  being  less  paralysed  than  the  rest. 

In  Marx's  patient  the  ophthalmoplegia  was  of  the 
external  type — that  is,  there  was  paralysis  of  the 
external  musculature  of  the  eye,  the  internal  muscula- 
ture being  unaffected. 

In  the  case  observed  by  Roberts  and  Williamson  the 
ophthalmoplegia  was  bilateral,  and  established  itself 
progressively  ;  the  left  eye,  situated  on  the  side  of  the 
woimd,  was  the  first  affected  ;  it  became  immobile,  the 
pupil  moderately  dilated  and  not  reacting  to  light.  On 
the  following  day  the  third  and  fourth  pairs  of  cranial 
nerves  on  the  right  side  became  paralysed,  and  the 
pupil  on  that  side  was  noticeably  contracted. 


KNOWN  ATYPICAL  FORMS  OF  TETANUS     733 

In  these  cases  the  ophthalmoplegia  was  total  from 
the  outset.  In  other  cases  it  was  at  first  restricted  to 
certain  muscles. 

Thus  paralysis  may  involve  the  whole  of  the  muscles 
innervated  by  the  common  oculomotor  nerve,  to  the 
exclusion  of  the  intrinsic  musculature. 

The  signs  of  a  paralysis  of  tetanic  origin  of  the  third 
pair  of  cranial  nerves  offer  no  special  character  to  dis- 
tinguish them  from  the  signs  of  ophthalmoplegia  of 
a  different  origin.  It  must  be  remembered,  however, 
that  when  the  paralysis  is  localised  only  in  some  of  the 
muscles  innervated  by  the  third  pair,  the  levator  palpe- 
brce  superioris  is  almost  invariably  the  muscle  most 
frequently  affected.  However,  in  the  case  observed  by 
Wahl  there  was  paralysis  of  the  two  right-hand  internal 
muscles  (divergent  bilateral  strabismus). 

The  isolated  paralysis  of  the  levator  is  often  partial, 
in  the  sense  that  the  patient  can  slightly  lift  the  upper 
eyelid  ;  but  this  movement  must  be  differentiated 
from  the  lifting  of  the  eyelid  which  may  be  effected 
by  the  compensatory  action  of  the  frontalis  muscle. 
Occasionally  the  ptosis  is  the  first  manifestation  of  the 
paralysis.  It  is  usually  unilateral  and  most  frequently 
situated  on  the  same  side  as  the  wound,  but  it  some- 
times happens  that  the  two  levator  muscles  are  simul- 
taneously involved.  Sometimes,  as  in  Rocliffe's  case, 
the  ptosis  is  more  accentuated  on  the  side  of  the 
wound. 

The  paralysis  of  the  sixth  pair  of  cranial  nerves  is 
rarer,  especially  the  isolated  form.  This  form  has  been 
reported  only  on  one  occasion.  It  is  usually  observed 
in  association  with  paralysis  of  the  third  and  fourth 
pairs.  Similarly,  the  isolated  paralysis  of  the  superior 
oblique  is  exceptional ;  only  one  case  is  known.     It  is 


734      THE  ABNORMAL  FORMS  OF  TETANUS 

usually  observed  in  conjunction  with  a  paralysis  of  the 
oculomotor  nerve. 

The  Situation  of  the  Ophthalmoplegia. — As  is  the  case 
with  facial  paralysis,  ophthalmoplegia  may  be  situated 
on  the  same  side  as  the  wound,  but  it  is  usually  either 
bilateral  from  the  first,  or  it  invades  the  two  ocular 
globes  successively.  Rarely  the  ptosis  and  ophthal- 
moplegia may  make  their  appearance  on  the  side 
opposite  to  the  wound. 

Pupillary  Disorders. — Pupillary  disorders  may  also 
be  observed,  either  simultaneously  with  the  paralysis 
or,  more  rarely,  isolated. 

These  disorders  have  been  noted  by  all  the  clinicians 
who  have  studied  cephalic  tetanus,  and  Albert,  in  his 
thesis,  mentions  that  in  this  atypical  form  the  sphincter 
of  the  iris  is  always  contracted,  and  the  pupil,  greatly 
diminished,  becomes  pinpoint  and  does  not  react  to 
light. 

Possibly  the  condition  of  myosis  present  is  due  to  the 
local  action  of  the  tetanic  toxin  on  the  sphincter  of  the 
iris. 

It  must  be  noted,  however,  that  Jacobson  has 
obsei*ved  mydriasis  in  a  case  of  cephalic  tetanus.  How- 
ever this  may  be,  in  spite  of  myosis,  accommodation  is 
normal,  at  all  events  in  the  beginning,  for  later  on  the 
test  becomes  difficult.  Moreover,  Lepine  and  Sarvonat 
discovered  that  in  their  patient  the  iris  dilated  readily 
under  the  influence  of  atropine. 

Amblyopia  has  also  been  noted  (Larrey,  Harkness), 
and  according  to  Chevalier  these  amblyopic  pheno- 
mena should  be  placed  in  the  category  of  amblyopia 
due  to  intoxication  without  lesion  of  the  fundus  of  the 
eye.  But  this  is  a  pure  hypothesis,  for  no  ophthalmo- 
scopic examination  had  been  made.     In  those  cases 


'       KNOWN  ATYPICAL  FORMS  OF  TETANUS     735 

in  which  it  was  possible  to  make  such  an  examina- 
tion, the  fundus  of  the  eye  was  found  to  be  normal  in 
four  cases,  and  hyperaemic  in  the  cases  observed  by 
Wahl,  Fromaget,  Lepine,  and  Sarvonat,  but  without 
other  lesion. 

Pathogenesis. — ^We  shall  not  insist  upon  the  different 
theories  successively  put  forward  in  order  to  explain 
these  forms  of  paralysis.  We  shall  cite,  as  matters  of 
historical  interest,  the  asthenic  theory  advanced  by 
Rose,  and  the  reflex  theory  supported  by  Sereins  and 
Houques,  but  the  infectious  theoiy  alone  appears  to 
explain  these  special  lesions.  The  experimental  in- 
vestigations of  Brunner,  Vaillard  and  Vincent  have 
indeed  demonstrated  that  the  paralysis  appears  later 
than  contraction,  and  is  due  to  a  greater  virulence  of 
the  tetanic  poison,  or  to  the  more  prolonged  action  of 
this  poison.  Moreover,  from  the  clinical  point  of  view, 
the  forms  of  cephalic  tetanus  which  are  accompanied 
by  paralysis  are  particularly  serious.  Further, 
anatomical  and  pathological  researches  show  that 
these  forms  of  paralysis  are  not  due  to  changes  in  the 
peripheral  nerves,  but  rather  to  cellular  lesions,  and  our 
clinical  knowledge  does  not  permit  us  to  entertain  the 
hypothesis  of  a  neuritic  origin.  The  ocular  paralysis 
observed  on  the  side  opposite  the  wound  can  only.be 
explained  by  a  nuclear  lesion — a  theory  which  seems 
to  receive  general  support — while  the  frequent  occur- 
rence of  bilateral  paralysis  must  also  be  due  to  the 
same  mechanism.  The  habitual  association  of  ocular 
paralysis  with  facial  paralysis,  the  persistence  of  the 
pupillary  reaction,  the  absence  of  blepharospasm,  and 
the  dissociated,  incomplete  type  of  the  paralysis  of  the 
common  oculomotor,  recall  the  clinical  features  of 
nuclear  ophthalmoplegia. 


736    THE  ABNORMAL  FORMS  OF  TETANUS 

This  nuclear  origin  is  further  rendered  probable  by 
the  presence  of  facial  paralysis,  which,  in  the  majority 
of  cases,  is  total,  and  which  may  be  situated  on  the 
opposite  side  to  the  wound. 

Finally,  a  last  argument  in  favour  of  this  origin  is  to 
be  found  in  the  fact  that  the  ophthalmoplegia  may  be 
associated  with  a  paralysis  of  the  hypoglossal,  and 
numerous  autopsies  have  led  to  the  discovery  of  lesions 
of  the  bulbar  nuclei,  especially  in  the  region  of  the 
facial  nerves. 

According  to  Worms,  these  forms  of  ocular  paralysis 
are  the  expression  of  a  polioencephalitis,  being  analogous 
in  this  to  post-diphtheritic  paralysis. 

As  to  the  route  followed  by  the  toxin,  if  we  go  by  the 
experimental  researches  of  Courmont  and  Doyon,  Marie 
and  Morax,  Meyer  and  Ransom,  we  may  consider  that 
paralysis  of  the  cranial  nerves  may  occur  in  two  different 
ways,  but  it  is  difficult  to  assert  that  one  mode  of  pro- 
pagation is  more  probable  than  the  other. 

1.  Through  the  medium  of  the  trigeminal,  lesions  of 
which  upon  the  face  are  of  frequent  occurrence.  In 
wounds  of  the  eyebrow,  for  example,  the  injured  supra- 
orbital nerve  may  lead  the  toxin  to  the  oblongata,  and 
the  tetanic  poison  having  infected  the  trigeminal,  may 
gradually  gain  the  nuclei  of  the  motor  nerves  of  the 
face  and  eyes,  where  it  causes  lesions  which  the  micro- 
scope reveals  with  difficulty. 

2.  Through  the  medium  of  the  motor  nerves  of  the 
face  (facial  and  common  oculomotor).  If  the  process 
is  readily  explicable  in  the  case  of  facial  paralysis,  it  is 
equally  so  in  the  case  of  ophthalmoplegia,  if  we  suppose, 
with  Duval  and  Mendel,  that  the  fibres  of  the  superior 
facial  nerve  which  innervate  the  frontal  muscles,  the 


KNOWN  ATYPICAL  FORMS  OF  TETANUS  737 

superciliary  muscles,  and  the  orbicular  muscles  of  the 
eyelids,  spring  either  from  the  external  oculomotor 
nerve  (Duval)  or  the  common  oculomotor  nerve 
(Mendel). 

If,  on  the  other  hand,  we  remember  that  in  most  cases 
of  ophthalmoplegia  the  v/ound  has  been  situated  in  the 
territory  innervated  by  the  third  pair  of  cranial  nerves 
we  may  suppose  that  the  toxin  reaches  the  oblongata 
by  way  of  a  branch  of  the  common  oculomotor  neive. 
Finally,  from  the  nucleus  of  the  common  oculomotor  or 
its  branches  the  toxin  may  reach  the  nuclei  of  the 
nerves  of  the  opposite  side. 

Diagnosis. — ^The  first  question  which  presents  itself 
in  a  case  of  cephalic  tetanus  with  paralysis  of  the  motor 
nerves  of  the  eye  is  whether  we  are  not  confronted  by  a 
faUie  ophthalmoplegia — that  is,  an  apparent  paralysis 
due  to  spasm  of  the  ocular  muscles.  In  this  connection 
it  is  possible,  as  the  result  of  a  superficial  examination, 
to  confound  the  paralysis  of  the  right  external  rectus 
with  spasm  of  its  antagonist,  the  right  internal  rectus. 

To  avoid  this  error  Borel  advises  that  the  field  of 
fixation  should  be  determined  by  placing  the  eye  at  the 
centre  of  the  perimeter,  the  head  being  immobilised. 
The  sound  eye  is  opened,  while  the  affected  eye  is  made 
to  follow  an  object  which  is  moved  from  the  centre 
toward  the  periphery. 

The  field  of  fixation  is  normal  in  the  case  of  spastic 
strabismus  and  limited  in  the  case  of  paralytic  stra- 
bismus. Borel  has  also  discovered  another  means  of 
differentiation  in  the  graphic  curve  giving  the  excur- 
sion of  the  ocular  movements.  This  curve  should  be 
contracted  in  the  one  case,  and  in  the  other  case  should 
assume  a  basin-like  form. 

In  the  sp^sm  Parinaud  notes  supplementary  con- 


738    TEE  ABNORMAL  FORMS  OF  TETANUS 

tractions — involuntary  blinking  of  the  eyelids,  fibrillary 
contractions  of  the  orbicularis,  a  lack  of  co-ordination 
and  an  abnormal  suddenness  of  muscular  movements, 
and  even  nystagmus.  Moreover,  while,  for  instance, 
in  paralysis  of  the  right-hand  external  oblique  adduc- 
tion is  normal,  and  abduction  suppressed,  in  the 
spasm,  as  in  the  convergent  strabismus,  the  movements 
are  of  normal  extent  and  readily  executed.  Finally 
the  spasms  are  inconstant,  while  the  paralysis  is 
fixed. 

Once  ophthalmoplegia  is  recognised  its  cause  must  be 
sought. 

(a)  If  the  patient  does  not  furnish  evidence  of  a 
previous  wound  or  traumatism,  we  may,  to  begin  with, 
consider  the  possibility  of  a  meningeal  lesion,  and  in 
particular  a  cerebrospinal  meningitis.  As  in  ophthal- 
moplegic tetanus,  we  may,  in  fact,  observe  stiffness  of 
the  neck  and  ocular  paralysis.  But  in  this  case  we  dis- 
cover high  fever  (104°  F.).  Although  partial  tetani- 
form  cramps  may  be  present,  there  is  no  trismus,  and 
the  masseteric  contraction  can  be  partially  or  wholly 
overcome.  Moreover,  in  tetanus  Kernig's  sign  is 
absent ;  in  many  cases,  for  that  matter,  it  would  be 
impossible  to  look  for  it,  on  account  of  the  intense 
muscular  contractions.  Lastly,  a  lumbar  puncture, 
and  the  chemical,  cytological,  and  bacteriological 
examination  of  the  cephalo-rachidian  fluid  will  enable 
us  to  remove  any  doubt. 

The  prodromal  symptoms  may  also  assist  the  diag- 
nosis. Shivering,  headache,  and  vomiting  do  not 
accompany  the  silent  invasion  of  cephalic  tetanus,  and 
while  the  intellectual  faculties  are  disordered  in  menin- 
gitis they  remain  unaffected  in  tetanus. 

The   form   of  tubercular  meningitis   in   the    adult, 


KNOWN  ATYPICAL  FORMS  OF  TETANUS   739 

described  by  Boix,  commencing  with  isolated  trismus, 
may  simulate  tetanus  with  paralysis  of  the  motor  nerves 
of  the  eye.  The  trismus  is  presently  followed  by  stiff- 
ness of  the  neck,  and  sometimes  by  dorsal  contractions, 
which  do  not  facilitate  a  differential  diagnosis.  But  in 
bacillary  meningitis  there  are  no  convulsive  spasms, 
and  hesitation  quickly  disappears  with  the  advent  of 
the  entire  symptomatic  train  of  the  meningeal  lesion  : 
high  temperature,  modifications  of  the  pulse,  Kernig's 
sign,  and  the  special  character  of  the  cerebro -spinal 
fluid. 

{b)  If  the  patient  exhibits  a  wound  resulting  from  a 
previous  traumatism  (a  fall  on  the  head  or  a  violent  blow 
in  that  region),  accompanied  by  ocular  paralysis,  we  may 
inquire  whether  the  ophthalmoplegia  is  not  due  simply 
to  a  fracture  of  the  orbit,  a  hypothesis  all  the  more 
possible  in  that  wounds  inflicted  by  firearms  are  liable 
to  involve  the  orbital  region. 

Considering  the  probability  of  tetanus,  this  is  in 
general  due  to  superficial,  localised,  and  insignificant 
wounds,  which  do  not  permit  us  to  suppose  the  existence 
of  a  considerable  traumatism.  In  the  contrary  event 
we  must  consider  the  possibility  oi  a.  fracture  with  intra- 
orbital haemorrhage,  and  the  formation  of  a  clot,  which, 
according  to  its  position  and  its  dimensions,  may  give 
rise  to  a  more  or  less  complete  immobility  of  the  eye, 
thus  simulating  paralysis. 

If  the  traumatism  which  has  determined  the  wound 
on  the  face  was  of  a  certain  severity,  we  may  also  pause 
to  consider  the  possibility  ot  a,  fracture  of  the  base  of  the 
skull,  with  signs  of  compression.  In  such  a  case  other 
and  graver  symptoms  will  be  observed  :  stertor,  dis- 
orders of  movement,  but  no  trismus ;  all  these  signs, 
moreover,  would  appear  at  the  time  of  the  accident, 


740        THE  ABNORMAL  FOBMS  OF  TETANUS 

while  in  tetanus  there  is  a  phase  of  incubation  lasting 
for  some  days. 

If  ocular  paralysis  following  upon  a  wound  in  the 
face  cannot  be  explained  by  a  fracture,  if  the  subject  is 
nervous,  presenting  all  the  signs  of  a  functional  neurosis, 
it  is  permissible  to  consider  the  possibility  of  an  ocular 
manifestation  of  hystero-traumatism. 

This  will  seem  all  the  more  possible  inasmuch  as 
under  the  influence  of  the  trauma  the  hysterical  mani- 
festation develops  in  the  neighbourhood  of  the  wound, 
and  because  in  this  neurosis  the  phenomena  of  spasm 
and  paralysis  are  very  often  associated. 

Parinaud,  examining  the  ocular  derangements  occur- 
ring in  hysteria,  has  shown  that  apart  from  pseudo- 
paralytic ptosis  the  hysterical  muscular  disorders  of 
vision  are  confined  almost  exclusively  to  modifications 
of  the  associated  movements  of  the  eyes.  Paralysis 
involves  only  the  voluntary  movements  ;  the  eyes  may 
move  instinctively  under  the  influence  of  numerous 
excitations  which  give  rise  to  ocular  movements  with- 
out the  direct  intervention  of  the  will. 

Lastly,  hysterical  ptosis  has  individual  signs  which 
enable  us  to  diagnose  it ;  it  is  not  permanent,  and  the 
eye  is  able  to  open  when  the  attention  is  quickly  engaged ; 
it  is  often  accompanied  by  photophobia  ;  the  eyebrow, 
instead  of  being  greatly  elevated,  is,  on  the  contrary, 
depressed. 

The  diagnosis  of  cephalic  tetanus  with  ophthalmo- 
plegia may  be  extremely  difficult  to  establish. 

The  clinician,  confronted  by  a  wound  of  the  face, 
even  an  insignificant  wound,  often  cicatrised,  accom- 
panied by  ocular  paralysis,  a  slight  facial  asymmetry, 
and  isolated  contractions,  should  consider  the  possi- 
bility of  tetanic  infection.    He  will  look  for  trismus,  and 


KNOWN  ATYPICAL  FORM 8  OF  TETANUS  "^^l 

in  the  absence  of  this  sign,  if  there  is  the  least  suspicion 
of  a  tetanic  origin,  he  should  imnpiediately  treat  his 
patient  accordingly,  without  waiting  for  the  occasion- 
ally tardy  appearance  of  confirmatory  symptoms. 

Prognosis. — Generally  speaking,  ocular  paralysis  is 
only  of  brief  duration,  and  even  in  some  fatal  cases  it 
has  disappeared  before  death. 

It  disappears  either  simultaneously  with  the  trismus 
and  the  facial  paralysis,  or  after  them. 

The  prognosis  of  the  ophthalmoplegia,  considered 
apart  from  the  other  tetanic  symptoms,  is  good,  since 
among  the  whole  of  the  cases  recorded  only  once  has 
it  persisted  for  as  long  as  three  months.  At  the  end  of 
this  period  Rocliffe's  patient  still  exhibited  diplopia 
and  a  slight  ptosis  in  the  left  eye. 

If  the  prognosis  is  difficult  to  establish  positively,  as 
we  have  only  a  limited  number  of  observations  to  go  by, 
it  is  nevertheless  noticeable  that  those  cases  in  which 
ophthalmoplegia  has  been  very  definitely  manifested 
have  had  a  fatal  termination. 

In  order  to  give  a  prognosis  we  must  take  into  account 
the  muscular  contractions,  the  temperature,  the  res- 
piration, and  above  all  the  duration  and  the  time  of 
the  first  appearance  of  the  tetanus.  Putting  aside  the 
unforeseen  complications  which  may  supervene,  we  may 
say  that  chronicity  is  a  factor  of  recovery ;  the  duration 
of  those  cases  which  have  recovered  has  varied  from 
four  to  twelve  weeks  (average,  seven  weeks). 

The  prognosis  is  more  serious  in  proportion  as  the 
tetanus  makes  its  first  appearance  at  an  earlier  date. 
Thus,  in  the  fatal  case  observed  by  Lepine  and  Sarvonat, 
the  period  of  incubation  was  five  days. 

This,  by  the  way,  is  a  prognostic  factor  common  to 
all  forms  of  tetanus  infection. 


743    THE  ABNORMAL  FORMS  OF  TETANUS 

The  treatment  of  this  variety  is  that  of  ordinary 
tetanus.  We  will  only  remark  that  if  the  ophthalmo- 
plegia persists  after  the  evolution  of  the  tetanus  is 
terminated  we  may  employ  local  electrical  treatment 
and  strychnine,  as  for  facial  paralysis. 


Cephalic  Tetanus  with  Paralysis  of  the 
Hypoglossal 

In  the  course  of  cephalic  tetanus  we  may  observe,  in 
association  with  facial  paralysis  and  ophthalmoplegia, 
a  paralysis  of  the  hypoglossal.  Such  observations  are 
exceptional.  Their  principal  interest  resides  in  the 
fact  that  from  the  pathogenic  point  of  view  they  argue 
in  favour  of  the  nuclear  origin  of  the  forms  of  paralysis 
occurring  in  cephalic  tetanus.  Clinically  speaking,  the 
invasion  of  the  hypoglossal  determines  a  syndrome  of 
labio-glosso-laryngeal  paralysis. 

The  different  forms  of  paralysis  which  characterise 
each  variety  of  cephalic  tetanus  are  often  found  to  be 
associated  in  the  same  patient,  and  there  is  a  particular 
clinical  type,  tliat  of  Rose's  "  cephalic  tetanus,"  which 
is  characterised  by  three  essential  signs  : 

1.  Contractions  localised  in  the  cervico-facial  region. 

2.  The  existence  of  facial  paralysis  which  may  attack 
the  facial  nerve,  the  motor  nerves  of  the  eye,  and  the 
hypoglossal. 

3.  An  essentially  chronic  development,  without  fever, 
the  general  condition  being  unaffected. 

We  may  therefore  resume  the  symptomatology  of 
cephalic  tetanus  in  a  fairly  simple  fashion  :  the  patient 
complains  that  he  cannot  open  his  mouth,  and  experi- 
ences the  greatest  difficulty  in  swallowing  food  ;  whence 
trismus  and  dysphagia.     The  symptoms  may  go  no 


KNOWN  ATYPICAL  FORMS  OF  TETANUS  743 

further  than  this  (dysphagic  and  hydrophobic  forms). 
But  in  general  the  patient  exhibits  a  more  or  less  accentu- 
ated facial  paralysis,  a  paralysis  affecting  the  wounded 
side,  a  paralysis  sometimes  difficult  to  discover  when 
there  is  contraction  of  the  muscles  of  the  opposite  side 
of  the  face  (Binet  and  Trenel).  To  determine  whether 
it  actually  exists  it  is  enough  to  instruct  the  patient  to 
make  an  effort  to  open  his  lips  or  his  eyelids.  If  he 
cannot  do  this  in  that  part  of  the  face  which  is  immobile 
and  inert,  there  is  really  paralysis  of  the  seventh  pair  of 
cranial  nerves.  This  is  the  facial  form  of  cephalic  tetanus. 
Occasionally  signs  of  ophthalmoplegia  associated  with 
facial  paralysis  make  their  appearance,  dominating 
the  clinical  picture  (Worms'  bulbo-paralytic  form). 
There  is  sometimes  paralysis  of  the  sixth  pair  of  cranial 
nerves,  sometimes  of  the  fourth  pair  ;  but  most  fre- 
quently it  is  the  common  oculomotor  which  is  involved. 
If  the  lesion  involves  only  some  of  its  fibres  a  greatly 
localised  paralysis  results,  affecting  either  the  levator 
palpebrae  superioris,  causing  ptosis,  or  the  motor 
muscles  of  the  eye,  giving  rise  to  strabismus,  or  the 
internal  musculature,  causing  loss  of  accommodation 
and  possibly  explaining  the  amblyopic  phenomena 
observed  in  certain  patients.  These  ophthalmoplegic 
phenomena  may  appear  before  the  facial  paralysis, 
the  ptosis  becoming  the  first  indication  of  cephalic 
tetanus.  Lastly,  the  hypoglossal  may  be  affected, 
with  the  labio-glosso-laryngeal  syndrome  predominant 
(fourth  form  of  cephalic  tetanus). 

Unilateral  Tetanus 

We  do  not  believe  that  there  is  such  a  thing  as  uni- 
lateral tetanus  characterised  by  the  sole  and  exclusive 


744    THE  ABNORMAL  FORMS  OF  TETANUS 

localisation  of  the  contractions  to  one  side  of  the  body. 
These  are  simply  cases  in  which  the  tetanic  symptoms 
persist  for  a  long  time  on  one  side  of  the  body  only,  and 
remain  very  predominant  on  that  side  during  the  period 
of  generalisation,  giving  rise  to  pleurothonotos. 

Properly  speaking,  there  is  here  no  question  of  an 
atypical  form,  so  we  shall  content  ourselves  with  the 
mention  of  this  particular  variety  of  the  tetanic  infection. 


PART  //.—LOCAL   TETANUS   OF 
THE   LIMBS 

CHAPTER  I 

OBSERVATIONS 

We  shall  eliminate  from  this  variety  of  tetanus  the  cases 
observed  by  Esau,  Boinet  and  Monges,  and  Curtillet 
and  Lombard,  in  which  the  tetanic  infection  was  not 
localised  in  the  initial  seat  of  infection  during  the  entire 
development  of  the  disease.  In  Esau's  observation, 
entitled  Local  tetanus  of  the  hand,  the  malady,  despite 
the  title,  was  local  only  during  a  first  period  ;  contrac- 
tures developed  in  the  left  upper  limb  seven  days  after 
a  traumatism  of  the  left  hand  ;  but  nine  days  after 
their  appearance  trismus  and  opisthonotos  appeared, 
thus  completing  the  clinical  picture  of  a  classical  case 
of  tetanus,  subacute  in  form,  predominant  on  the  left. 
Similarly,  the  patient  observed  by  Boinet  and  Monges 
had  received  a  knife-wound  in  the  left  supraspinous 
fossa.  Five  days  later  tetanus  set  in,  with  contractures 
in  the  left  superior  member,  and  these  contractures 
remained  localised  for  a  week  ;  but  at  the  end  of  this 
period  they  invaded  the  muscles  of  the  neck  and  face, 
the  right  upper  limb  and  the  lower  limbs  remaining  un- 
affected. Lastly,  in  the  case  reported  by  Curtillet  and 
Lombard  the  malady  was  once  again  rather  an  incom- 
plete tetanus, .  monoplegic  to  begin  with,  then  a  local 
tetanus,  for  the  contractures,  at  first  confined  to  the 

745 


746   THE  ABNORMA  L  FORMS  OF  TETANUS 

wounded  upper  limb,  invaded  the  muscles  of  the  chest 
and  neck. 

The  different  observations  which  we  are  about  to 
reproduce  here  fall,  on  the  other  hand,  under  the 
heading  of  local  tetanus,  as  in  these  cases  there  was  never 
any  trace  of  generalisation.  The  cases  observed  by 
Pozzi,  Routier,  Laval,  Monod,  Carnot  and  ourselves 
are  peculiarly  typical,  and  enable  us  to  sketch  the 
clinical  history  of  this  peculiar  local  form.  We  have 
no  intention  of  bringing  together  all  the  published 
observations  of  atypical  tetanus  of  the  limbs,  but  only 
those  which  appear  to  us  to  be  particularly  interesting, 
and  which  will  enable  us  to  describe  the  clinical  develop- 
ment of  local  tetanus  of  the  limbs. 


Observation  I.  (Courtellemont).  —  Tetanus   confined  to  the 
left-hand  lower  limb 

-,  sixty  years  of  age,  usually  enjoyed  good  health  ;  his 


antecedents  were  not  in  any  way  remarkable.  Towards  the 
end  of  July,  1909,  while  working  in  his  garden,  he  slightly 
wounded  his  left  foot  with  the  tooth  of  a  rake.  He  attended 
to  the  small  wound,  which  in  appearance  was  insignificant, 
and  in  a  few  days  it  was  healed.  On  Wednesday,  the  11th 
of  August,  or  abowt  fifteen  days  after  the  accident,  the  left 
foot  became  slightly  heavy,  stiff,  and  extended  at  the  ankle 
joint  in  the  position  of  a  talipes  equinus  ;  at  the  same  time 
there  was  an  incomplete  trismus.  On  the  next  day  and  up 
to  the  15th  August  these  sensations  and  this  deformation  of 
the  foot  became  more  accentuated,  without  any  modification 
of  the  trismus. 

During  the  whole  of  this  first  period  the  disorders  con- 
sisted of  a  slight  trismus  and  contractures  involving  the  left 
leg,  a  trace  of  the  affection  in  the  neck  and  trunk,  and 
abundant  sweats.  The  trismus  never  amounted  to  absolute 
closing  of  the  jaws  ;  At  went  no  further  than  making  it 
impossible  for  the  patient  to  open  his  mouth  completely.  It 
was  permanent,  and  exaggerated  by  a  spasm  on  the  approach 


OBSEllVATIONS  747 

of  food.  The  subject  also  found  it  extremely  difficult  to  eat, 
being  unable  to  masticate. 

In  the  left  lower  limb  there  was  a  permanent  contracture, 
and  painful  paroxysms  were  localised  in  the  foot  and  the  leg. 
The  foot  was  fixed  in  the  position  of  talipes  equinus,  the  toes 
were  flexed  and  the  contracted  calf  formed  a  hard  mass.  In 
this  condition,  intermittent  intensifications  of  the  contractures 
occurred.  These  paroxysms  were  very  painful ;  they  occurred 
as  the  result  of  a  sudden  noise  (the  ringing  of  a  bell,  for 
example),  or  of  movements  (when  the  patient  turned  in  his 
bed  or  tried  to  raise  himself).  The  threat  of  generalisation 
showed  itself  at  the  moment  of  these  intensified  contractures 
of  the  left  foot  and  leg ;  indeed,  when  the  paroxysms  were 
violent  the  whole  body  seemed  to  feel  the  effect.  The  trismus 
increased,  the  trunk  became  stiff,  and  the  three  remaining 
limbs  also  possibly  exhibited  a  slight  stiffness,  but  the  patient 
could  not  be  positive  of  this  last  point.  On  Sunday,  the 
15th  August,  Dr  Hurtel  found  the  patient  lying  on  his  back, 
incapable  of  sitting  up  on  account  of  the  stiffness  of  the 
trunk,  the  paroxysms  being  excited  by  every  attempt  to 
stand  up  or  sit  down. 

Dr  Hurtel  diagnosed  tetanus,  prescribed  absolute  repose, 
and  darkness,  and  administered  chloral  (3  to  8  grammes  daily, 
according  to  the  intensity  of  the  paroxysms).  By  the  even- 
ing, and  on  the  following  day,  the  l6th,  the  condition  of  the 
patient  had  improved,  the  trismus  was  attenuated,  and  all 
trace  of  generalisation  had  disappeared,  but  the  condition 
of  the  left  leg  remained  much  the  same. 

We  saw  the  patient  on  the  I7th  August.  He  was  in  bed, 
the  left  lower  limb  lying  abducted,  the  lower  leg  half-flexed 
at  the  knee;  the  foot  was  in  hyper-extension— that  is, 
stretched  out  like  a  horse's  foot — and  this  attitude  appeared 
to  be  pushed  to  the  maximum  degree ;  the  five  toes  were 
strongly  flexed.  All  the  muscles  of  the  leg  were  contrac- 
tured ;  they  were  hard ;  the  relief  of  the  soleus  and  the 
twin  muscles  of  the  calf  was  greatly  accentuated,  the  appear- 
ance being  extremely  striking.  There  was  extreme  con- 
tracture of  the  muscles  of  the  leg  and  foot,  most  marked  in  the 
muscles  of  the  calf.  This  contracture  was  permanent.  It 
was  impossible  to  modify  the  attitude  of  ^he  foot,  but  the 
knee  could  be  completely  straightened ;  the  hip  was  mobile, 
and  the  thigh  could  be  flexed  upon  the  pelvis,  although  it 


748    THE  ABNORMA  L  FORMS  OF  TETANUS 

offered  a  little  resistance.  Owing  to  the  condition  of  the 
foot  the  patient  could  not  sit  down,  save  on  the  edge  of 
the  bed  with  the  leg  pendent.  There  were  no  contractures 
of  the  muscles  of  the  back  or  neck,  and  no  trismus. 

Sometimes,  when  the  patient  made  a  movement,  a  painful 
cramp  opcurred  in  the  left  leg  and  foot ;  this  was  a  paroxysm 
confined  to  these  two  regions. 

The  patient  was  cheerful,  speaking  with  ease.  He 
presented  no  sign  of  visceral  lesion. 

We  administered  an  epidural  injection  of  10  c.c  of  anti- 
tetanic  serum,  and  prescribed  chloral,  in  doses  of  6  to  8 
grammes  in  the  twenty-four  hours.  The  following  week 
went  by  without  aggravation,  but  without  notable  improve- 
ment, the  symptoms  remaining  entirely  confined  to  the  left 
leg  and  foot,  and  there  were,  rarely,  slight  paroxysms,  also 
confined  to  the  same  regions.  During  this  time  the  physician 
in  charsre  of  the  case  administered  three  subcutaneous 
injections  of  10  c.c.  of  antitetanic  serum. 

On  the  23rd  the  dose  of  chloral  was  decreased  to  3  or  4 
grammes ;  the  following  night  an  aggravation  of  the  dis- 
orders appeared ;  numerous  and  painful  cramps  of  the  left 
leg,  a  few  attacks  of  cramp  in  the  right  leg,  some  abdominal 
colics,  and  some  lumbar  pains  due  to  spasmodic  contracture 
of  the  muscles  in  that  region. 

On  the  morning  of  the  24th  the  right  leg  was  slightly 
stiff,  and  the  dose  of  chloral  was  immediately  increased. 
In  the  afternoon  the  right  leg  was  again  normal,  but  the 
lower  portion  of  the  abdominal  wall  was  rather  hard ;  apart 
from  this  sign  the  disorders  were  still  strictly  localised  in  the 
left  leg  and  foot.  However,  the  spasmodic  intensifications 
and  the  cramps  were  slightly  more  frequent  than  on  the 
occasion  of  our  first  consultation ;  we  produced  them,  in 
particular,  by  seeking  to  correct  the  equinism. 

A  fresh  epidural  injection  of  10  c.c.  of  antitetanic  serum 
was  administered.  From  this  moment  the  improvement 
became  progressive ;  but  the  patient  retained  for  some  six 
weeks  a  stiffness  of  the  left  foot  and  leg,  and  he  could  not 
place  the  foot  on  the  ground  without  experiencing  a  painful 
cramp.  Complete  recovery  was  not  accomplished  until  after 
this  long  period  had  elapsed. 


OBSERVATIONS  749 


Observation  II.  (S.  Pozzi). — Localised  tetanus  (early) 

H ,  a  soldier  wounded  on  the  25th  September  1915, 

near  Souchez,  by  shell-splinters  which  traversed  and  splin- 
tered the  bones  of  the  left-hand  tarsal  region ;  the  wounded 
man  was  given  his  first  dressing  on  the  25th  September, 
four  hours  after  being  wounded,  at  the  advanced  dressing 
station;  he  received  his  second  dressing  on  the  28th,  Or 
three  days  after  he  was  wounded,  at  Aubigny  ;  on  the  evening 
of  the  29th  he  reached  Broca,  where  a  third  dressing  was 
appHed  (iodoform  gauze). 

The  preventive  injection  of  antitetanic  serum  (10  c.c.)  was 
administered  on  the  28th — that  is,  three  days  after  the  patient 
was  wounded.  On  examination,  on  the  29th,  it  was  discovered 
that  the  two  wounds  of  entry  and  emergence  were  exuding 
a  little  pus.  There  was  no  oedema  of  the  foot.  The  pain  in 
the  region  of  the  wound  was  not  very  severe.  The  general 
condition  appeared  to  be  good.  The  rectal  temperature  did 
not  exceed  982°  F. 

On  the  30th  September  a  drain  was  passed  through  the 
wound,  feeton-wise.  During  the  day  the  pain  in  the  region 
of  the  wound  increased  ;  then  a  few  convulsive  jerks  occurred, 
solely  in  the  left  leg,  succeeding  one  another  at  a  few  minutes' 
interval.  These  jerks  were  very  painful,  and  attained  their 
maximum  when  the  slightest  movement  was  made. 

There  was  no  contracture  or  cramp  in  any  other  part  of  the 
body  ;  no  trace  of  trismus.  In  the  evening  the  temperature 
reached  100-4°  F. 

From  the  1st  to  the  4th  of  October  the  pain  arising  from 
the  convulsions  increased  each  day.  The  jerks  occurred  with 
shorter  intervals,  and  became  more  violent  in  the  left  leg  and 
thigh.     The  temperature  rose  to  104°. 

On  the  5th  October  an  extensive  opening  up  of  the  wounds 
was  effected.  The  course  of  the  wound  was  explored,  and  a 
few  free  splinters  of  bone  were  withdrawn.  On  the  evening 
after  the  operation  the  temperature  rose  to  104*7°  F. 

On  the  6th  October  the  temperature  dropped  a  little,  but 
the  convulsive  jerks  became  extremely  frequent.  Every  ten 
seconds  the  whole  of  the  wounded  limb  was  the  seat  of  the 
most  excruciatingly  painful  contractions ;  towards  the  close 
of  the  day  a  few  slight  jerks  occurred  in  the  right  leg. 


750     THE  ABJS^OBIIAL  FORMS  OF  TETAXUS 

No  spasm  existed  as  yet  in  the  region  of  the  upper  limbs ; 
and  there  was  no  trace  of  trismus  or  contracture  of  the  trunk 
muscles.  This  day  the  second  preventive  injection  of  10  c.c. 
of  antitetanic  serum  was  made. 

On  the  7th  the  convulsive  jerks  increased  in  frequency  and 
in  violence^  especially  on  the  wounded  side.  They  continued, 
though  much  less  violent,  on  the  right  side.  The  patient 
was  screaming  with  pain,  and  could  be  calmed  neither  by 
morphia,  nor  pantopon,  nor  large  doses  of  chloral. 

The  evening  temperature  was  104 '9°  F. 

On  the  morning  of  the  8th  there  was  no  remission  of  the 
jerks.  The  left-hand  lower  limb  was  contractured,  the  calf 
being  slightly  flexed  on  the  thigh  and  the  thigh  on  the 
pelvis. 

Locally,  the  cicatrisation  of  the  wounds  was  not  progressing. 
The  suppuration  had  slightly  diminished,  but  there  was  no 
progress  toward  healing. 

The  temperature  being  103'6  °  F,,  and  the  pains  atrocious, 
it  was  decided  that  amputation  should  be  performed ;  the 
patient  insistently  demanded  it.  It  was  hoped  thereby  to 
arrest  the  nervous  symptoms  by  abolishing  their  point  of 
departure. 

Supramalleolar  amputation  was  performed ;  no  sutures 
being  applied. 

Operative  Sequelae. — During  the  days  following  the  opera- 
tion the  temperature  fell,  becoming  normal  on  the  10th,  or 
the  second  day  after  the  operation.  The  operative  wound 
presented  a  most  favourable  appearance. 

As  for  the  convulsive  jerks,  they  had  diminished  neither 
in  frequency  nor  in  violence.  On  the  contrary,  the  pains 
were  so  violent  that  the  wounded  man  had  not  a  moment's 
repose ;  he  knelt  in  his  bed,  seeking  a  less  painful  position. 
The  jerks  were  as  marked  on  the  right  side  as  on  the  left  for 
two  days  ;  then  they  diminished  on  the  sound  side,  and  finally 
disappeared  entirely.  The  wounded  side  was  contractured, 
the  limbs  being  flexed.  The  pain  was  more  violent  when  an 
attempt  was  made  to  extend  the  limb. 

No  therapeutic  agent  could  overcome  the  pain.  Morphia, 
large  doses  of  bromide  of  potassium  (8  to  12  grammes  daily), 
pantopon,  and  extract  of  valerian  were  employed,  and  an 
application  of  radium  was  made  without  success.  Only  the 
bromide  and  the  pantopon  gave  a  little  relief.     The  bromide 


OBSERVATIONS  751 

was  continued  for  ten  days  ;  the  pantopon  was  continued 
until  the  end  of  October. 

The  jerks  and  pains  then  became  less  violent.  But  the 
contracture  increased  ;  the  flexion  of  the  calf  upon  the  thigh 
was  most  pronounced. 

There  was  no  trophic  trouble  in  the  lower  legs. 

Following  the  advice  given  by  Dr  Veiilon,  Director  of  the 
Laboratory  at  the  Clhiique  Infantile  des  Enfanls  j^Ialades, 
massive  and  successive  injections  of  antitetanic  serum  were 
administered  : 

23  October 40  c.c. 

24  October 40  ,, 

25  October 20  „ 

This  active  treatment  did  noc  appear  to  produce  any 
marked  change.  From  the  25th  October  to  the  30th  the 
jerks  progressively  diminished  in  frequency  and  violence, 
and  were  of  rare  occurrence,  but  the  contracture  was 
maintained. 

Locally,  the  cicatrisation  of  the  stump  proceeded  normally. 
To  remedy  the  persistent  contractures  subcutaneous  injections 
of  perphoxene  were  tried  on  the  1st  and  2nd  of  Novernber. 
The  pain  caused  by  the  injection  rendered  it  intolerable  to 
the  patient,  who,  however,  had  at  this  time  already  exhibited 
a  remission. 

On  the  6th  November  the  pains  momentarily  reappeared 
in  the  left  limb,  with  a  few  jerks.  The  right  limb  was 
thenceforth  unaffected.  The  same  day,  as  a  sedative,  bi- 
bromide  of  codein  was  tried,  in  subcutaneous  injection,  the 
dose  being  002  grammes  per  injection.  The  patient 
appeared  to  be  relieved  by  this,  and  was  able  to  sleep  better 
than  after  the  other  sedatives. 

After  the  first  painful  period,  the  patient  passed  through 
a  period  of  permanent  contracture  without  pain.  On  the 
7th  December  his  left  lower  leg  remained  flexed  at  right 
angles  to  the  thigh,  owing  to  the  powerful  contracture  of  the 
flexora  of  the  knee,  the  strained  tendons  of  which  could  be 
felt  by  the  finger  in,  the  popliteal  region.  There  was  also  a 
slight  contracture  of  the  adductor  muscles.  Complete  ex- 
tension of  the  leg  was  therefore  absolutely  impossible  ,  more- 
over, the  gastrocnemius  was  hard  and  rigid  as  a  lump  of 
wood. 


752    THE  ABNORMAL  FORMS  OF  TETANUS 

Pressure,  unless  it  was  exaggerated,  was  not  painful  in  the 
region  of  this  muscle,  nor  in  the  region  of  the  thigh  muscles. 
It  resulted,  from  this  permanent  contracture  of  the  muscles, 
that  the  patient  was  not  yet  able  to  benefit  by  an  appliance 
which  would  enable  him  to  walk  without  crutches. 

The  considerable  improvement  which  has  for  some  days 
been  observed  under  the  influence  of  massage  gives  reason 
to  hope  that  the  contracture  will  presently  cease  entirely, 
before  the  onset  of  muscular  atrophy. 

This  observation  is  that  of  a  localised  tetanus  intermediate 
between  the  monoplegic  type  (predominant)  and  the  para- 
plegic type,  which  was  established  only  for  a  few  days, 
thereupon  disappearing  without  leaving  any  traces. 


Observation  III.   (Ch.   Monod). — Localised  tetanus   of  the 

right  arm 

Joseph-Marie  Le  Br ,  thirty  years  of  age,  a  sergeant  in 

the  8th  Battalion  of  Chasseurs  a  Pied,  wounded,  on  the  25th 
September  1915,  at  Auberive,  entered  Auxiliary  Hospital 
No.  35  on  the  29th  September. 

First  dressing,  seventeen  hours  after  the  wound ;  first 
antitetanic  injection,  the  27th  of  September,  fifty  hours  after 
the  wound. 

Diagtiosis. — Wound  caused  by  a  bullet  fired  from  a  distance 
of  eight  yards.  Orifice  of  entry,  small,  on  the  posterior  face 
of  the  right  arm.  Enormous  wound  of  emergence  occupy- 
ing almost  the  whole  anterior  portion  of  the  forearm. 
Second  orifice  a  little  below  the  first.  The  two  orifices  were 
drained. 

Progress  of  Maladi^. — 29th  September.  Temperature, 
102-75°-1044°  F. 

Moist  dressing  with  Labarraque's  solution.     Drainage. 

1st  Oc/o6er.— Temperature,  103 -7°- 102  2°  F.  A  patch  of 
total  gangrene  (skin  and  muscles)  extending  to  the  anterior 
internal  face  of  the  forearm,  having  commenced  with  an 
isolated  black  spot  above  the  wrist.  Extensive  cleansing 
with  thermocautery  was  carried  as  far  as  the  bone,  without 
anywhere  finding  a  sound  muscle.  On  puncture  with  ther- 
mocautery, there  was  an  obvious  escape  of  gases.  Moist 
dressing  (Labarraque's  solution). 


OBSEBVATIONS  753 

3rd  October. — Temperature  101  •6°-102'7°  F.  The  gangrene 
has  extended  to  the  hand.  Same  treatment,  serum,  electrargol 
applied.     Patient  suffering  greatly. 

4>th  October.  — Temperature,  1 0 1  '6° -99  *  1  °  F.  Circular  amputa- 
tion of  the  upper  arm  in  its  middle  portion. 

5th,  6th,  1th  Odo6er.— Temperature,  100-4°-10M°,  99-7°- 
100-2°,  98-2°-99-l°,  F. 

%ih  October. — Patient  gets  up.     Suffers  little  pain. 

9lh  October. — Shooting  pains  in  the  stump,  the  pains 
increase  during  the  night.     Temperature,  98'2°-98'2°  F. 

lOth  October.— Temperature,  97-9°-99-7°  F.  Very  violent 
jerks  in  the  stump  and  shoulder,  recurring  sometimes  every 
three  or  four  minutes,  and  forcing  a  cry  from  the  wounded 
man.  These  jerks  are  not  clonic  but  tonic,  the  member 
being  convulsively  drawn  toward  the  trunk.     Morphia. 

Wth  Odofter.— Temperature,  100-2°-100-2°.  Threads  re- 
moved prematurely  under  ether.  Carbolic  acid,  5  per  cent, 
solution,  sprayed  over  the  stump.  Chloral,  2  grammes. 
Antitetanic  injection  (the  first  since  that  given  at  the 
outset,  fifty  hours  after  the  wound).  About  five  hours 
later  the  jerks  diminished  ;  the  patient  was  greatly  relieved. 
The  spraying  was  discontinued. 

12iA  Odo6er.— Temperature,  100-2°-102-6°  F. 

\Mh  Oc/o6er.— Temperature,  99'7°-103-6°  F.  The  patient 
still  suffering  a  little  ;  slight  contractions. 

\5th  Odo/)er.— Temperature,  98-9°-100-4°  F.  At  2  p.m., 
3  P.M.,  and  5.30  p.m.,  tetaniform  paroxysms,  with  stiffness 
of  the  neck  and  hardening  of  facial  muscles.  The  hand 
contracts  like  a  claw,  and  is  slowly  drawn  towards  the  right 
armpit ;  the  head  is  violently  thrown  back.  The  patient 
loses  consciousness.  Returns  to  consciousness  at  the  end 
of  five  minutes,  but  cannot  at  first  speak,  and  does  not 
understand  what  is  said  to  him.  He  is  dripping  with 
perspiration.  At  the  end  of  a  quarter  of  an  hour  he  has 
fully  recovered  consciousness,  and  the  slight  paroxysms 
recommence  as  before. 

The  patient  explains  that  at  the  moment  of  the  paroxysm 
it  seemed  as  though  someone  seized  his  arms  and  forced  him 
to  whirl  them  violently  round  like  the  sails  of  a  windmill. 
Excruciating  pain.  The  same  symptoms  are  exactly  repro- 
duced in  all  three  paroxysms.  As  soon  as  he  comes  to 
himself  the  patient  has  no  difficulty  in  opening  his  mouth 


754      THE  ABNORMAL  FORMS  OF  TETANUS 

to  its  full  extent  and  in  swallowing.     The  patient  is  isolated. 
Six  grammes  of  chloral. 

l6ih  October. — Contractures  not  quite  so  painful  in  the 
wounded  arm.  Chloral,  8  grammes ;  subcutaneous  injection 
of  10  c.c.  of  sulphate  of  magnesia,  according  to  the  formula : 

Sulphate  of  magnesia  crystallised  with  7 

molecules  of  water  of  crystallisation      .  250  grammes 

Distilled  water  ....         1000         ,, 

During  the  night  the  jerks  become  very  paiiiful  and  force 
cries  from  the  patient  every  two  or  three  minutes. 

A  fresh  injection  of  sulphate  of  magnesia. 

The  patient  becomes  quiet,  and  sleeps. 

lltk  October. — Jerks  still  painful  and  very  frequent. 
Eight  grammes  chloral.  Three  injections  of  sulphate  of 
magnesia. 

I8th  October. — Same  condition.  Chloral,  8  grammes. 
Three  injections  of  sulphate  of  magnesia. 

19th  October. — ^ Jerks  less  painful,  and  sometimes  occurring 
at  intervals  of  several  hours  only.  Chloral,  4  grammes.  Two 
injections  of  sulphate  of  magnesia. 

20th  October. — Improvement  continues.  Six  grammes 
chloral.     Two  injections  of  sulphate  of  rhagnesia. 

21*^  October. — Second  antitetanic  injection.  Six  grammes 
chloral.     Two  injections  of  sulphate  of  magnesia. 

Before  the  injection  of  serum  the  patient  had  two 
paroxysms  at  which  no  one  was  present.  He  says  he  did 
not  lose  consciousness,  and  that  the  paroxysms  were  less 
violent  than  those  of  the  1 5th  October,  just  a  week  earlier. 
He  was  next  seen  dripping  with  perspiration,  and  for  a  time 
the  pain  disappeared.  After  the  injection  a  fresh  crisis  at  a 
time  when  the  patient  was  alone. 

22nrf  October. — Two  slight  paroxysms  in  the  morning. 
Seven  grammes  chloral.  Three  injections  of  sulphati^  of 
magnesia. 

23rd  October. — Greatly  exhausted.  Suffering  greatly. 
Six  grammes  chloral.  Three  injections  of  sulphate  of 
magnesia. 

24fth  October. — Third  antetetanic  injection.  Six  grammes 
chloral.     Three  injections  of  sulphate  of  magnesia. 

25th  October. — Quieter.  Fourth  antitetanic  injection.  Six 
grammes  chloral.     Three  injections  of  sulphate  of  magnesia. 


OBSERVATIONS  755 

26th  October. — Fifth  antitetanic  injection.  Six  grammes 
chloral.     Three  injections  of  sulphate  of  magnesia. 

27th  October. — Sixth  antitetanic  injection.  Four  grammes 
chloral.     Three  injections  of  sulphate  of  magnesia. 

In  the  morning  one  injection  of  sulphate  of  magnesia  is 
given.  The  patient  appearing  better,  it  is  decided  to  stop 
these  injections  and  to  diminish  the  chloral.  But  the  pains 
having  recurred  with  great  violence  towards  the  evening, 
with  cries  at  each  jerk,  two  injections  are  given  close 
together  (8  and  8.30  p.m.).     The  night  is  quiet. 

ZHth  October.  —  Patient  much  better.  Four  grammes 
chloral.  Patient  joking.  Often  goes  several  hours  without 
jerks.     They  are  slight  and  not  very  painful. 

2tid  November. — Eighth  antitetanic  injection. 

8th  November. — The  patient  no  longer  has  violent  jerks, 
except  in  the  morning,  when  his  bed  is  approached.  If  one 
calls  him,  even  gently,  he  wakes  with  a  start,  uttering  a  cry. 
The  arm  remains  painful. 

9th  November.  —  Ninth  antitetanic  injection.  Wound 
almost  entirely  cicatrised.  Temperature  oscillates  henceforth 
between  98°  and  99-5°. 

20th  November. — The  patient  is  completely  cured. 


Observation  IV.  (Routier). — Abnormal  localised  tetanus 

On  the  18th  May  1915  a  wounded  man  came  under 
ray  care  for  a  penetrating  wound  of  the  upper  and 
posterior  region  of  the  thorax,  on  the  left,  with  pleural 
effusion. 

Wounded  a  few  days  before,  he  had  been  given  an 
injection  of  antitetanic  serum. 

On  his  arrival  the  patient  appeared  greatly  prostrated; 
there  was  abundant  suppuration,  with  high  temperature. 
On  the  following  day,  the  19th,  the  countenance  was 
anxious.  The  patient  complained  of  sharp  pains  in  the  left 
arm,  and  temperature  was  104°  F. 

This  grave  condition  was  not  modified  on  the  20th,  but 
on  the  21st  the  left  arm,  still  the  seat  of  violent  pains,  was 
anim.ated  by  involuntary  movements,  by  incessant  clonic 
contractions. 

The    forearm    flexed    itself    suddenly    upon    the    upper 


756    THE  ABNORMAL  FORMS  OF  TETANUS 

arm,  while  the  latter  was  thrown  violently  forwards  and 
outwards. 

The  wrist  and  fingers  remained  unaffected.  The  pain 
was  violent,  and  the  movements  continuous,  with  exacer- 
bations occurring  in  paroxysms. 

Much  puzzled  to  explain  these  pains  and  spasmodic 
movements,  I  begged  my  colleague  and  friend,  Babinski,  to 
come  and  give  me  his  opinion.  After  a  very  careful  examina- 
tion Babinski  confirmed  our  apprehensions,  affirming  that 
this  was  indeed  a  case  of  abnormal  tetanus,  and  added  that 
its  termination  would  probably  be  fatal.  On  the  following 
day,  in  fact,  we  observed  trismus,  pleurothonotos,  and  then 
stiffness  of  the  neck. 

The  pulse  quickly  became  very  variable,  sometimes  being 
almost  normal,  and  sometimes  very  rapid,  while  the  respira- 
tion assumed  a  jerky  character.  At  the  onset  of  the  accidents 
we  administered  a  fresh  injection  of  antitetanic  serum,  and 
gave  the  patient,  who  was  isolated,  10  grammes  of  chloral 
per  diem  with  morphia  at  night.  This  treatment,  continued 
day  by  day,  did  not  abolish  the  paroxysms.  The  patient 
died  of  asphyxia  on  3rd  June. 


Observation  V.  (Routier) 

A  naval  sub-lieutenant  was  wounded  on  25th  September 
in  the  right  scapular  region,  by  a  large  shell-splinter.  Dressed 
at  the  Quatre- Vents  field  hospital,  the  wound  was  opened 
up,  and  a  large  hsematoma  evacuated  which  made,  as  it  were, 
a  fistula  in  the  posterior  portion  of  the  upper  arm ;  and  two 
drains  were  placed  in  it.  An  antitetanic  injection  was  said 
to  have  been  given  on  the  26th,  twenty-four  hours  after  the 
wound. 

The  patient  was  evacuated  to  Necker,  with  a  large 
suppurating  wound  in  the  right  scapular  region,  but  it  had 
a  very  good  aspect,  with  two  orifices  near  the  bottom. 

The  patient  was  not  suffering,  complaining  only  of  the 
weight  of  his  arm.  The  general  condition  was  excellent ; 
the  temperature  on  the  first  evening  was  100 '4°  F,  but  on  the 
following  day  it  became  normal. 

Treatment  was  confined  to  dressings  every  second  day, 
moistened  with  a  solution  of  chloride  of  magnesium. 


OBSERVATIONS  757 

He  was  in  such  good  condition  that  I  authorised  his 
evacuation  into  the  country,  but  this  was  not  effected. 

On  the  8th  October  the  patient  complained  suddenly  of 
a  very  severe  pain  in  the  right  thigh.  Nothing  visible. 
Temperature,  98  -6°  F.  in  the  morning;  99  '5°  F.  in  the 
evening. 

On  the  9th  the  pain  in  the  right  thigh  became  intolerable. 
The  muscles  were  slightly  contractured ;  there  was  marked 
adductor  spasm.  Violent  headache  during  the  day ;  slight 
stiffness  of  the  neck ;  exaggeration  of  the  reflexes  of  the 
whole  of  the  right  lower  limb  with  epileptiform  spasms. 
Temperature,  99-7°  F.  in  the  morning;  101-3°  F.  in  the 
evening.     Isolation  and  1 0  grammes  of  chloral  ordered. 

On  the  10th  the  pains  persisted  with  paroxysmal  crises; 
the  stiffness  of  tLe  back  of  the  neck  was  more  marked.  There 
was  also  lumbar  stiffness.  The  patient  was  very  nervous ; 
he  had  photophobia :  he  complained  the  moment  anyone 
made  the  slightest  sound  or  directly  one  approached  him. 
Morning  temperature,  100'4°  ;  evening,  10r3°.  The  wound 
seemed  to  be  doing  well.  Ten  grammes  of  chloral  and  two 
subcutaneous  injections  of  a  solution  of  calcium  hypophosphate 
and  sodium  persulphate. 

On  the  11th  the  same  signs,  with  the  addition  of  a  slight 
trismus.  Morning  temperature,  101*3°  F. ;  evening,  102  2°  F. 
Ten  grammes  chloral  and  three  injections. 

The  tongue  was  dry ;  the  patient  drank  but  little. 

This  same  condition  continued,  and  we  pursued  the  same 
treatment  until  the  1 5th  October.  The  temperature  then 
fell  to  99 '7°  F.  The  phenomena  of  contracture  and  the  pains 
amended;  despite  this  10  grammes  of  chloral  was  given,  and 
the  subcutaneous  injections  were  reduced  to  two,  then  to  one, 
until  the  13th  October ;  the  patient  still  had  a  few  cramps  in 
the  back  of  the  neck  ;  finally,  on  the  22nd,  all  seemed  to 
become  normal  once  more,  and  all  danger  was  averted. 

The  painful  phenomena  were  predominant.  There  were 
also  contractures  chiefly  affecting  the  adductors  of  the  thigh, 
and  a  slight  trismus  and  stiffness  of  the  muscles  of  the  back 
of  the  neck,  but  if  a  very  close  watch  had  not  been  kept  these 
indications  might  have  been  unnoticed  at  the  time  of  their 
commencement. 


758      THE  ABXORMAL  FOBMS  OF  TETANUS 


Observation  VI.  (Routier) 

M.  G ,  wounded  on  the  2.5th  September^  entered  the 

hospital  at  Necker  on  the  30th,  He  had  a  compound  fracture 
of  the  left  elbow^  and  a  wound  on  the  left  hip,  both  being  in 
good  condition.  Everything  seemed  as  thongh  destined  to 
advance  toward  recovery  when,  on  the  17th  October,  the 
patient  exhibited  a  very  painful  contracture  of  the  whole  of 
the  left  lower  limb,  the  thigh  being  flexed  up  on  the  pelvis, 
the  lower  leg  flexed  at  the  knee-joint ;  the  toes  were  strongly 
flexed  ;  all  the  muscles  were  riarid.  The  limb  was  like  wood. 
The  reflexes  were  exaggerated,  with  epileptiform  twitching. 
Slight  pain  in  the  neck,  without  stiffness  ;  no  trismus  ;  the 
temperature,  which  since  the  8th  October  had  been  normal, 
rose  to  102  6^  F. 

The  patient  was  isolated.  Ten  grammes  of  chloral  and 
two  injections  of  the  solution  as  in  the  previous  case.  The 
same  symptoms  persisting  on  the  18th  and  1,9th,  I  prescribed 
the  addition  of  an  injection  of  morphia  every  night. 

On  the  2 1st  the  contracture  of  the  toes  appeared  to  be 
vielding. 

On  the  22nd  the  contracture  of  the  entire  limb  was  no 
longer  continuous. 

We  observed  alternative  contraction  and  flaccidity  of  the 
muscles.     Vomiting  in  the  night.      Parched  tongue. 

On  the  2.3rd  the  contracture  was  greatly  diminished.  The 
tongue  remained  par'^hed  ;  intense  thirst. 

On  the  24th  the  patient  died  in  the  night. 


Observation  VII.  (Routier) 

A  soldier  of  the  8th  Colonial  Regiment  was  wounded  on 
the  25th  September,  and  entered  the  Necker  hospital  on  the 
loth  October,  He  had  two  wounds  (each  with  two  orifices), 
one  in  the  upper  portion  of  each  thigh,  and  a  slight  wound 
of  the  perineum,  due  perhaps  to  the  same  projectile,  which 
had  not  remairted  in  the  wounds.  When  receiving  first  aid 
he  had  been  given  an  antitetanic  fnjection. 

Everything  appeared  sufliciently  benign.  On  the  26th 
October  the  patient  suddenly   complained  of  pains  in  the 


OBSERVATIONS  759 

right  knee,  whicn  was  neither  red  nor  swollen  ;  the  lower  leg 
was  strongly  flexed  up  at  the  knee.  The  patient  refused  to 
stretch  it  out,  and  cried  out  when  attempting  to  extend  it. 

On  the  27th  the  flexion  was  reduced.  The  leg  was 
placed  on  a  Boeckel  splint.  Four  grammes  salicylate  of 
sodium. 

The  temperature,  which  until  then  had  oscillated  between 
98-6°  and  100-1.'' F.,  rose  to  104°  in  the  morning,  and 
registered  100'2'  F.  at  night.  The  facial  aspect  argued  in 
favour  of  typhoid  fever,  but  the  sero-diagnosis  was  negative. 

On  the  28th  the  Bceckel  splint  was  removed,  as  it  could 
be  no  longer  borne  ;  immediately  the  leg  flexed  itself  forcibly 
at  the  hip  and  knee  joints. 

The  muscles  of  the  abdominal  wall  contracted  in  turn,  and 
during  the  day  contraction  of  the  left  arm  was  noted.  On 
the  29th,  30th,  and  31st  October  all  these  signs  increased; 
one  could  no  longer  approach  the  patient  without  his 
crying  out. 

Isolation  of  patient.  Ten  grammes  chloral.  Three  in- 
jections of  the  solution  already  mentioned. 

Treatment  continued  until  the  5th  November,  when  the 
chloral  was  discontinued,  the  patient  showing  symptoms  of 
poisoning. 

On  the  following  day  6  grammes  of  chloral  was  given, 
per  rectum,  but  it  was  not  retained.  The  patient  was 
developing  a  sacral  bedsore.  Pain  still  violent,  and  the 
contracture  of  the  adductors  of  the  thigh  very  marked. 

During  this  contracture  of  the  muscles  of  the  leg  the 
foot  always  remained  mobile  and  supple. 

On  the  10th  November,  6  grammes  of  chloralwas  given 
on  account  of  the  greater  violence  of  the  pains. 

On  the  11th  the  patient  could  extend  his  right  leg, 
using  his  left  foot  for  the  purpose,  pushing  his  right  foot 
with  it. 

On  the  13th  the  chloral  and  subcutaneous  injections  were 
discontinued  ;  they  had  been  continued  without  interruption 
from  the  beginning,  to  the  number  of  three  per  diem. 

On  the  1 5th  the  pains  and  the  contracture  reappeared. 
The  6  grammes  of  chloral  and  the  three  subcutaneous 
injections  were  resumed. 

On  the  16th  the  pains  and  contractures  had  ceased. 
However,  the  treatment  was  continued. 


760       THE  ABNORMAL  FORMS  OF  TETANUS 

The  chloral  was  stopped  on  the  17th;  the  injections  on 
the  18th. 

The  patient  is  recovering. 

Observation  VIII.  (Routier) 

A  soldier,  thirty-three  years  of  age,  wounded  at  Souchez 
on  the  24th  September,  entered  Hospital  106  on  the  1st 
October,  having  been  given  one  antitetanic  injection. 

He  had  a  wound  in  the  head,  in  the  right  frontal  region, 
without  fractures,  numerous  wounds  of  the  left  upper  limb, 
the  shoulder,  and  the  forearm.  Many  wounds  in  the  two 
thighs. 

A  few  days  after  his  arrival,  pleural  effusion  on  the  left 
side. 

\6th  November. — Pleurotomy  with  costal  resection.  Enor- 
mous evacuation  of  pus. 

\1th  November. — Pains  and  muscular  twitchings  of  the 
whole  of  the  left  lower  limb.  Permanent  contracture  in 
extension. 

Reflexes  greatly  exaggerated  on  the  left;  normal  on  the 
right. 

1  ^th  November. — Disappearance  of  the  muscular  twitchings. 

l^th  November. — Contracture  diminished. 

The  same  signs  persisted  until  the  26th. 

The  contracture  no  longer  appeared  save  on  the  occasion 
of  a  voluntary  movement. 

SOth  November. — This  day  the  movements  of  flexion  were 
still  effected  slowly,  and  were  preceded  by  a  contracture  of 
all  the  muscles  of  the  right  lower  limb,  which  disappeared 
when  the  limb  was  flexed. 

From  the  commencement  of  the  spasms  the  patient  was 
isolated  and  subjected  to  treatment  by  chloral,  6  grammes 
daily,  morphia,  and  subcutaneous  injections  of  Bottu's 
solution. 

All  treatment  was  discontinued  on  the  26th ;  the  patient 
had  recovered. 

Observation  IX.  (Laval). — Tetanus  localised  in  one  leg 

Andr6  M. ,  of  the Regiment  of  Infantry,  twenty- 
three  years  of  age,  entered  the  hospital  on  the  13th  April,  at 


OBSERVATIONS  761 

1 1  A.M.  He  ,had  been  wounded  two  days  earlier,  on  the 
11th,  at  Les  Eparges,  by  shell-splinters. 

Dressed  for  the  first  time  a  quarter  of  an  hour  later,  on 
the  spot,  he  received  a  second  dressing  at  the  temporary 
field  hospital  at  7  p.m.  ;  and  a  third  on  the  following  day, 
the  12th,  at  4  a.m.  Finally,  a  fourth  and  last  dressing 
was  administered  at  2  p.m.  at  Verdun.  There,  it  was 
stated,  a  shell-splinter  was  extracted  from  the  wound  in  his 
chest. 

No  antitetanic  injection. 

M ,  being  examined  on  the  13th  April,  presented  a 

wound  of  the  left  lower  region  of  the  sternum,  apparently 
superficial,  and  a  perforating  wound  of  the  left  lower  leg, 
the  orifice  of  entry  at  the  juncture  of  the  lower  third  and 
the  middle  third,  the  orifice  of  emergence  three-fingers' - 
breadth  below  the  mid-line  of  the  knee-joint. 

General  anaesthesia  by  ethyl  chloride ;  the  orifices  of 
entrance  and  emergence  of  the  shell-splinters  in  the  lower 
leg  were  enlarged.  The  wound  was  cleaned  out  with  hypo- 
chlorite solution,  4  per  cent. 

Moist  dressing.  Immediately  afterwards  an  injection  of 
10  c.c.  of  antitetanic  serum  was  given. 

The  fever  gradually  decreasing  day  by  day,  and  the 
local  condition  appearing  to  improve  at  the  same  time,  the 
treatment  was  confined  to  the  daily  cleaning  of  the  wounds 
with  hypochlorite  solution  until  the  ipth  April. 

From  this  date  the  clinical  picture  underwent  a  trans- 
formation. Even  on  the  day  before  the  patient  had  com- 
plained of  feeling  violent  pains  in  the  wounded  leg.  On  the 
19th  he  was  examined  by  X-rays,  when  a  foreign  body  of 
some  size  was  discovered  in  the  antero-external  region  of  the 
lower  leg,  in  its  middle  third.  The  two  orifices,  therefore, 
did  not  correspond  with  the  orifices  of  entry  and  emergence 
of  one  projectile  ;  there  was  no  single  perforating  wound,  but 
two  distinct  wounds,  one  of  which  still  retained  the  foreign 
body  which  had  caused  it ;  the  other  perhaps  was  a  surgical 
wound. 

An  hour  later,  under  chloroform,  an  incision  was  made 
in  the  direction  of  the  anterior  tibial  artery,  five-fingers' - 
breadth  below  the  wound.  Under  the  superficial  aponeurosis, 
after  the  separation  of  the  tibialis  anticus,  fetid  gases  and 
yellowish-red  pus   escaped  from  the  depth  of  the  tissues. 


762   THE  ABNORMAL  FORMS  OF  TETANUS 

The  finger  being  introduced  withdrew  a  fragment  of  a  shell 
from  the  inter-osseous  region ;  this  was  situated  on  its 
anterior  aspect.  In  the  depth  of  the  cavity  from  which  this 
was  extracted  the  forefinger  discovered  and  withdrew  a  wad 
of  debris  from  the  patient's  clothing,  the  total  volume  being 
that  of  a  small  nut. 

The  wound  was  cleaned  with  Javal's  solution. 

Drainage. — The  temperature  was  normal.  The  question  of 
evacuation  was  about  to  be  considered,  when  on  the  morning 
of  the  23rd  there  was  a  fresh  surprise :  the  lower  limb  was 
strongly  contractured  in  the  region  of  the  foot,  which  was 
flexed  with  the  toes  in  extension.  At  the  same  time  the 
wound  from  which  the  foreign  bodies  had  been  withdrawn 
was  suppurating  profusely,  and  in  the  neighbourhood  of 
the  wound  the  inflamed  lyniphatic  network  could  be  seen 
descending  toward  the  thigh. 

The  patient,  interrogated  as  to  the  exact  period  when 
what  he  called  his  "cramps"  commenced,  admitted  to  us 
that  he  had  had  them  for  four  days ;  that  they  commenced 
in  the  foot,  and  gradually  extended  to  the  whole  lower  leg, 
but  knowing  that  there  was  a  question  of  evacuating  him 
he  did  his  utmost  to  prevent  anyone  discovering  this  when 
dressing  his  wound. 

We  immediately  administered  a  fresh  injection  of  anti- 
tetanic  serum,  20  c.c.  In  addition  to  this  two  injections  of 
carbolic  acid,  20  c.c.  of  a  1  per  cent,  solution  were  given  morn- 
ing and  evening.  At  the  same  time  we  prescribed  two  doses 
of  chloral  per  rectum  (4  grammes)  in  the  24  hours. 

On  the  following  day,  the  24th,  the  quantity  of  carbolic 
acid  solution  was  increased  to  80  c.c.  per  diem,  given  in  two 
doses,  and  was  continued  thus  for  seven  consecutive  days, 
then  diminished  to  .50  c.C;  for  the  four  following  days.  The 
chloral  was  continued  at  the  rate  of  8  grammes  per  diem  the 
whole  time  (11  days). 

On  the  24th  the  entire  lower  limb  was  in  a  state  of  con- 
tracture, in  forced  extension  ;  foot,  lower  leg,  and  thigh 
formed  a  whole  rigid  as  a  bar  of  iron,  which  seemed  welded 
to  the  pelvis. 

At  the  same  time  the  wounded  man  complained  of  violent 
pains  in  the  form  of  troublesome  cramps. 

On  the  25th  the  spasm  began  to  diminish  ;  raising  the 
thigh  in  one  hand  and  pressing  the  other  hand  on  the  lower 


OBSERVATIONS  763 

leg,  one  could  now  cause  a  slight,  very  slight  flexure  of  the 
knee,  barely  amounting  to  two  or  three  degrees. 

On  the  26th  the  patient  suffered  less  acutely  ;  with  a  great 
deal  of  effort  he  managed  to  lift  his  knee  slightly  from  the 
plane  of  the  bed,  and  he  himself  repeated  the  very  slight 
flexion  produced  by  us  the  day  before.  On  the  following 
days   the   improvement   continued.      On  the  "4th   May,  for 

example,  M —  was  flexing  the  lower  leg  freely  upon  the 

thigh,  and  with  more  difficulty  the  thigh  upon  the  pelvis. 
As  for  the  foot,  it  was  still  forcibly  flexed,  the  toes  drawn 
up  by  the  extensors,  whose  tendons  had  the  appearance  of 
stretched  cords  on  the  dorsum  of  the  foot.  Nevertheless,  a 
few  slight  movements  of  the  toes  were  seen  to  occur. 

On  the  14th  May — that  is,  about  a  month  after  the  wound — 
twenty-four  days  after  the  first  signs  of  tetanus,  the  patient 
had  completely  recovered  from  this  complication.  His 
wound  was  advancing  favourably  toward  cicatrisation. 

This  was  a  case  of  monoplegic  tetanus  which  appeared 
about  eight  days  after  the  wound,  in  a  man  who  was  not 
injected  until  forty-eight  hours  after  the  wound. 

Observation  X.  (Laval) 

Andre  M ,  twenty  years  of  age,  was  wounded  at  1  o'clock 

in  the  morning  of  the  18th  October,  at  Eparges,  by  a  grenade. 

Dressed  half-an-hour  later  at  the  field  ambulance  ;  second 
dressing,  with  operation,  at  the  M hospital,  at  1 1  o'clock. 

Antitetanic  serum  a  few  hours  later. 

On  arriving  in  hospital  on  the  morning  of  the  21st  October 
the  presence  of  two  wounds  was  noted.  One,  a  hand's-breadth 
in  width,  occupying  the  whole  of  the  right-hand  thoraco- 
abdominal region,  appeared  superficial.  The  other,  in  the 
retro-trochanterian  region  on  the  same  side,  was  penetrating  ; 
the  splinter  which  caused  it  was  said  to  have  been  extracted 
on  the  18th.  One  could  still  see  the  trace  of  the  incision 
made  on  the  antero-external  face  of  the  thigh,  about  four 
inches  from  the  orifice  of  entry. 

The  treatment  consisted  of  cleaning  the  thoraco-abdominal 
wound  with  hydrogen  peroxide,  and  applying  a  dressing 
moistened  with  Javal's  solution,  4  per  cent.  The  wound  on 
the  hip,  which  exhibited  no  inflammatory  reaction,  was  dressed 
with  the  same  solution. 


764   THE  ABNORMAL  FORMS  OF  TETANUS 

The  dressing  was  performed  regularly  every  day,  when  on 

the  24th  October — that  is,  six  days  after  the  wound — M 

suddenly  complained  of  pain  in  the  right  ankle. 

Very  disturbed  night. 

27th  October. — The  pains  increased  and  assumed  the  form 
of  cramps,  which  made  the  patient  cry.    Morphia  was  given. 

At  2  P.M.  the  thigh  and  lower  leg  were  the  seat  of  horribly 
painful  spasmodic  contractions.  During  the  spasm  the  limb 
would  violently  extend,  as  though  under  the  impulse  of  a 
stretched  spring,  and  toes,  foot,  lower  leg,  and  thigh  formed 
a  rigid  whole.  During  this  tonic  convulsion  the  patient 
literally  roared  with  pain,  this  lasting  25  to  30  seconds  ; 
then  a  remission  occurred.  The  limb  resumed  its  normal 
aspect,  but  at  the  end  of  a  few  seconds  the  convulsion 
reappeared. 

These  were  evidently  tetanic  convulsions. 

Treatment. — 1.  Antitetanic  serum,  20  c.c. 

2.  Injection  of  dilute  carbolic,  1  in  100,  20  c.c,  night  and 
morning. 

3.  Chloral,  per  rectum,  3  grammes  whenever  the  patient 
began  once  more  to  complain  of  the  pain. 

In  consideration  of  the  severity  of  the  case,  we 

1.  Injected  l60  c.c.  of  antitetanic  serum,  at  the  rate  of 
20  c.c.  per  diem,  until  the  3 1st  October,  except  on  the  29th 
and  30th,  when  we  injected  30  c.c.  each  time. 

2.  The  injections  of  carbolic  acid  were  increased  from  40  c.c. 
to  80  c.c.  daily,  and  were  then  decreased  to  40  c.c. ;  they 
were  not  discontinued  until  the  8th  November.  Very  well 
tolerated. 

3.  The  average  amount  of  chloral  given  per  rectum  was 
13  grammes  in  the  24  hours,  except  for  three  days,  when 
we  were  obliged,  in  order  to  quiet  the  patient,  to  go  up 
to  18  grammes.  This  medicament  was  discontinued  on 
the  8th  November,  simultaneously  with  the  carbolic  acid 
injections. 

8tk  November. — All  spasms  had  ceased  ;  the  malady  would 
be  regarded  as  arrested.  The  spasms  had  never  extended 
beyond  the  right  lower  limb.  For  three  days  the  pelvic 
muscles  participated  in  the  rigidity,  but  the  latter  never 
mounted  higher,  nor  did  it  reach  the  lower  limb  on  the 
other  side. 


OBSERVATIONS  765 


Observation  XI.  (Camot). — Local  and  late-appearing 

tetanus 

A  soldier  was  wounded  in  the  left  arm  by  a  shell-splinter 
on  the  l6th  June  1915,  and  evacuated  after  an  injection  of 
10  c.c.  of  antitetanic  serum. 

The  wound  healed  in  a  fortnight ;  nevertheless,  on  the 
thirtieth  day  a  small  blister  appeared  in  the  region  of  the 
wound,  with  a  drop  of  pus  in  it. 

From  this  time  the  patient  felt,  at  short  intervals,  slight 
pains  in  the  wounded  arm,  but  these  did  not  seem  to  be  of 
any  great  importance.  The  patient  was  therefore  allowed 
out,  and  then,  on  the  6th  August,  sent  to  his  depot.  On  his 
return  the  arm  had  become  painful  and  its  contracture  pre- 
vented extension ;  he  was  exempted  from  service  for  a  week. 
Finally,  the  tetanic  phenomena  being  very  plainly  defined, 
he  was  sent  to  the  hospital  for  contagious  diseases  at  Epinal, 
on  the  19th  August  1915,  or  more  than  two  months  after  the 
initial  wound  and  the  preventive  antitetanic  injection. 

On  his  arrival  the  patient  exhibited  a  permanent  local 
contracture  of  the  left  upper  limb,  with  tetanic  spasms.  The 
contracted  arm  was  pressed  against  the  thorax,  the  forearm 
flexed  and  supported  by  the  sound  hand. 

Occasionally  it  would  be  thrown  suddenly  forward  by  a 
painful  spasm  lasting  some  seconds.  This  spasm  was  repeated 
several  times  per  minute;  it  was  excited  by  the  slightest 
sound,  or  an  emotion  would  cause  it. 

Although  the  tetanus  was  almost  entirely  localised  to  the 
wounded  limb,  a  slight  stiffness  was  observed  in  the  back  of 
the  neck,  a  slight  strabismus,  and  a  few  rare  cramps  in  the 
right  arm  and  the  legs. 

No  trismus :  no  difficulty  of  deglutition ;  no  dyspnoea ;  no 
spasms  of  the  respiratory  muscles. 

The  wound,  situated  on  the  anterior  face  of  the  upper  arm, 
a  few  fingers'-breadth  from  the  bend  of  the  elbow,  was  entirely 
cicatrised ;  it  appeared  neither  red  nor  oedematous,  and  there 
was  no  discharge  from  it.     The  temperature  was  101 '3°  F. 

Immediately  after  the  patient's  arrival  an  intravenous 
injection  of  40  c  c.  of  antitetanic  serum  was  administei'ed, 
but  as  the  subject  had  already  been  given  10  c.c.  of  serum 
two  months  earlier  the  possibility  of  anaphylactic  accidents 


Z^6    THE  ABNORMAL  FORMS  OF  TETANUS 

was  feared,  and  Besredka's  method  of  administering  very 
small  initial  doses  was  practised. 

On  the  following  day,  the  20th  August,  little  modification  ; 
the  tetanic  paroxysms  were  intense,  localised  almost  wholly 
in  the  left  arm. 

On  account  of  the  local  character  of  the  contracture  (and 
also  of  the  slightly  abnormal  strabismus)  the  nervous  condition 
of  the  subject  was  examined,  and  the  cerebro-spinal  fluid  was 
drawn  off;  it  was  normal.  Advantage  was  taken  of  the 
lumbar  puncture  to  administer  an  intra-rachidian  injection  of 
20  c.c,  of  serum  ;  there  was  no  anaphylactic  reaction.  The 
tetanic  cramps,  far  from  diminishing,  increased  in  violence 
and  intensity. 

The  temperature  was  101  6°  F. 

Two  days  later  it  was  decided  to  explore  the  seat  of  the 
old  wound,  in  search  of  pus  or  a  foreign  body  which  might 
explain  the  deposition  and  late  revivescence  of  tetanic 
spores. 

The  incision  was  made  right  through  the  cicatricial  tissue, 
but  neither  pus  nor  fragments  of  clothing  were  discovered  ; 
the  only  slightly  abnormal  fact  was  a  discontinuity  of  the 
tissues  which  made  it  possible  to  introduce  a  grooved  probe 
to  a  depth  of  2|  inches,  but  there  was  no  oozing.  Neverthe- 
less, an  injection  of  10  c.c.  of  antitetanic  serum  was  made  in 
the  region  of  the  wound. 

On  the  other  hand,  a  series  of  deep  injections  of  serum 
(30  c.c.)  was  made  along  the  course  of  the  nerves,  on  the 
internal  face  of  the  biceps,  towards  the  armpit,  or  in  all  an 
interstitial  injection  of  40  c.c.  of  antitetanic  serum. 

A  slight  improvement  was  visible  as  regards  the  intensity 
of  the  crises,  but  this  was  due  chiefly  to  the  chloral 
(6  grammes  daily). 

The  temperature  fell,  and  on  the  22nd  was  only  99'1°  F. 
in  the  morning,  and  100*2°  F.  at  night. 

On  the  22nd  an  intravenous  injection  of  40  c.c.  of  anti- 
tetanic serum  was  administered. 

On  the  23rd  an  intravenous  injection  of  20  c.c. 

The  improvement  continued,  but  without  accentuation, 
and  the  teta*iic  cramps  still  persisted,  although  a  little  less 
violent.     The  chloral  was  continued. 

By  this  date  the  patient  had  in  all  received,  iiff  addition  to 
the   10  c.c.   of  the   preventive    injection,   and    without    any 


OBSERVATIONS  767 

anaphylactic  accident,  l60  c.c.  by  intravenous  injection, 
20  c.c.  by  intra-rachidian  injection,  and  40  c.c.  by  inter- 
stitial and  paranervous  injections. 

On  the  26th  the  temperature  was  tending  to  rise,  and  in 
the  morning  was  100*4°  F.  The  tetanic  contractions  appeared 
to  be  increasing ;  there  was  once  more  a  slight  stiffness  of  the 
back  of  the  neck,  and  a  few  cramps  in  the  opposite  arm  and 
the  legs.  It  was  decided  once  again  to  inject  20  c.c.  of  serum 
by  intravenous  injection,  but  hardly  had  the  injection  been 
administered  when  the  patient's  expression  changed ;  he 
became  congested,  and  he  complained  of  sensations  of  heat 
and  general  malaise.  He  felt  suffocated,  became  cyanosed, 
and  was  conscious  of  a  sensation  of  extreme  anguish,  with 
difficulty  in  breathing,  and  retrosternal  pain  ;  at  the  same 
time  the  pulse  became  thread-like  and  could  not  be  counted ; 
an  extreme  fall  of  blood  pressure  manifested  itself.  In  short, 
an  intensely  dramatic  clinical  picture  was  suddenly  mani- 
fested— precisely  that  which  has  been  experimentally  observed 
after  the  "  releasing  injection  "  in  cases  of  Anaphylactic  shock. 
After  a  few  agonising  minutes  the  purplish  face  grew  ruddy 
again,  and  profuse  perspiration  appeared  on  the  face  and 
limbs,  but  exclusively  on  the  non-tetanised  side.  However, 
during  the  whole  day  the  patient  remained  a  prey  to  extreme 
anxiety.  The  pulse  was  1 40 ;  the  low  blood  pressure  continued, 
and  the  situation  remained  serious.  ^ 

The  tetanic  paroxysms  had  not,  however,  ceased ;  they 
were  both  frequent  and  severe  ;  they  were  still  predominantly 
localised  in  the  left  arm,  but  a  few  occurred  in  the  legs  and 
the  right  arm.  The  dysphagia  was  So  great  that  the  patient 
could  not  ftven  .swallow  fluids.  The  anaphylactic  shock 
seemed,  at  this  moment,  to  have  accentuated  the  tetanic 
phenomena. 

On  the  following-  day,  the  27th  August,  in  the  morning, 
and  without  any  further  injection,  the  patient,  who  appeared 
for  the  time  being  out  of  danger,  was  suddenly  attacked  by 
symptoms  like  those  of  the  previous  day.  The  face  became 
cyanosed ;  the  heart  was  disordered ;  dyspnoea  suddenly  set 
in,  violent  and  paroxysmal ;  the  anxiety  became  extreme, 
with  a  sensation  of  imminent  death  ;  the  pulse  could  not  be 
counted,  the  hypotension  was  considerable,  and  once  again 
profuse  sweats  covered  the  right  side,  which  was  not  tetanised. 
Under   the   influence    of    injection    of  ether,    caffeine,   and 


768    THE  ABNORMAL  FORMS  OF  TETANUS 

adrenalim  solution  the  blood  pressure  increased,  and  the 
anaphylactic  symptoms  once  more  became  attenuated. 

Nevertheless,  the  pulse  remained  low  tension  and  thread- 
like and  rapid  (140)  the  whole  of  that  day.  The  temperature 
was  102-2°  F.  on  the  evening  of  the  27th,  and  99-8°  F.  on  the 
morning  of  the  28th.  The  anxiety  persisted,  with  psychical 
excitement.  The  tetanic  cramps  were  still  exacerbated  in 
the  left  arm ;  a  few  occurring  even  in  the  legs  and  the  right 
arm.  There  was  moderate  stiffness  of  the  back  of  the  neck. 
No  trismus  ;  dysphagia  highly  accentuated. 

The  anaphylactic  symptoms  continued,  with  less  violence, 
for  some  days,  characterised  by  hypotension,  tachycardia 
(140),  and  extreme  malaise. 

The  temperature  remained  high:  103"1°,  103*5°. 

Locally  the  wound  had  become  red,  oedematous,  and 
indurated,  and  so,  for  that  matter,  had  all  the  regions  in 
which  the  serum  had  been  injected,  but  without  necrosis 
(local  anaphylaxis). 

Then,  rather  suddenly,  from  the  fourth  d.  y  onwards,  the 
temperature  fell  to  102°  F.  on  the  evening  of  the  30th  and 
99-8°,  99-3°  F.  on  the  31st. 

The  pulse  fell  from  140  to  112  per  minute.  The  anxiety 
was  considerably  alleviated ;  confidence  returned.  The 
tetanic  cramps  themselves  diminished  in  intensity  and 
frequency  (only  12  in  the  24  hours),  but  there  was  still, 
in  particular,  a  permanent  plastic  contracture  of  the  forearm 
upon  the  upper  arm. 

The  dysphagia  had  disappeared  ;  the  patient  was  drinking, 
and  his  appetite  was  returning. 

[n  short,  five  days  after  the  anaphylactic  shock  a  true 
critical  period  supervened,  with  rapid  amelioration  of  all 
the  symptoms — not  only  the  anaphylactic  symptoms,  but 
the  tetanic  symptoms  also,  and  with  a  general  return  to  the 
normal  state. 

From  thio  moment  the  tetanic  paroxysms  diminished 
progressively.  The  permanent  contracture  persisted  for 
some  time  longer,  with  reflex  hyper  -  excitability.  The 
subject  remained  all  day  with  the  left  forearm  flexed  upon 
the  upper  arm,  the  upper  arm  pressed  against  the  thorax, 
the  sound  hand  supporting  the  left  arm  to  avoid  positions 
of  extreme  contraction. 

For  hours  he  remained  with  a  weight  suspended  to  the 


OBSERVATIONS  769 

affected  limb,  in  order  to  effect  its  extension  progressively 
and  slowly.  There  were  no  further  painful  cramps.  The 
patient  gradually  recovered  strength.  He  left,  convalescent, 
on  the  15th  October,  still  retaining  a  slight  contracture 
(in  flexion)  of  the  left  upper  limb,  which  did  not  prevent  its 
employment. 


Observation  XII.  (Eauzier  and  Ester  in  a  thesis  by  Senor 
Ramirez). — Montpellier,  July,  1915.  Late-appearing 
tetanus  localised  in  the  lower  limb 

-,  twenty-two  years  of  age,  was  wounded  on  the  1 7th 


January  1915.  Slight  wound  in  the  right  foot,  with  small 
fragment  of  shell  enclosed,  and  a  second  very  superficial 
wound  of  the  lower  leg.  The  shell-splinter  was  removed 
and  an  injection  of  serum  given  immediately  after  the 
wound.  Intervention  in  the  region  of  the  cicatrix  on  the 
foot,  after  radiography,  on  account  of  recent  pains  and 
spasms  (21st  April  1915).     No  other  projectiles. 

Since  the  operation,  persistence  and  recrudescence  of 
the  painful  contractures  in  the  region  of  the  wounded 
limb. 

This,  at  the  moment  of  the  spasm,  became  hard  as  wood 
along  its  whole  length,  and  absolutely  rigid.  On  inspection 
one  could  see  the  contracted  masses  of  muscle  in  prominent 
relief.  The  spasms  were  accompanied  by  very  violent  pains, 
forcing  cries  from  the  patient.  They  were  awakened  by  the 
slightest  touch,  an  exploration  of  any  kind,  or  the  least 
excitation  of  the  senses  (a  noise,  etc.).  Nothing  in  the 
region  of  the  arms,  excepting  an  occasional  and  transient 
stiffness  of  the  right  arm. 

A  few  contractions  of  the  face  were  noted,  but  no  trismus, 
no  cervical  contracture,  and  no  dyspnoea. 

The  temperature  never  exceeded  99*3°  F. 

The  patient  was  treated  with  serum,  carbolic  acid,  and 
large  doses  of  chloral.     No  respiratory  or  digestive  disorders. 

Examination. — Complete  rigidity  of  the  lower  limbs,  above 
all  of  the  right  lower  limb,  provoking  a  veritable  appearance 
of  ankylosis  at  moments,  and  diminishing  at  intervals. 

Nothing  in  the  region  of  the  upper  limbs,  face,  neck,  or 
throat. 


770   THE  ABNORMAL  FORMS  OF  TETANUS 

The  patient  could  not  sit  down.  General  hypersesthesia 
was  noted  on  giving  injections. 

The  reflexes  appeared  to  be  abolished,  and  there  was  no 
Babinski's  sign  ;  the  pupils  were  normal. 

The  intelligence  was  maintained,  but  greatly  depressed. 

On  pressure  in  the  region  of  the  left  iliac  fossa,  a  marked 
feeling  of  strangulation  was  noted. 

No  indications  in  chest  or  heart. 

Urine  normal. 

Chloral  from  the  30th  April  to  the  12th  May,  at  che  rate 
of  10  grammes  in  the  24  hours. 

This  was  progessively  diminished  until  the  loth  May. 

Antitetanic  injections  commenced  the  4th  May,  finished 
the  14th  May. 

Injections  of  carbolic  acid  commenced  the  4th  May,  dis- 
continued the  19th  May.  The  affected  leg  gradually  became 
flexed  after  the  J 4th,  and  was  finally  folded  right  back;  it 
was  only  after  the  lapse  of  some  days  that  it  began  to 
straighten  itself  again.     Stiffness  ceased  on  the  19th  May. 


Observation  XIII.  (M.  Henri  Bouctuet) 

H (Georges),  of  the  1905  class,  discharged  for  endo- 
carditis on  the  8th  July  1908,  was  re-enlisted  at  his  own 
request  on  the  8th  August  1914.  Appointed  to  the  26'th 
Battalion  of  Chasseurs  a  Pied. 

Wounded  on  the  6th  September  1914,  at  noon,  during  the 
attack  on  the  Abbaye  Wood,  near  Saint-Andre  (Meuse), 
where  he  was  acting  as  a  sniper.  Remained  in  this  wood 
with  several  comrades  grievously  wounded,  like  himself, 
until  the  10th  September,  feeding  on  blackberries  and 
drinking  rain-water  caught  in  the  hollows  of  leaves.  He 
had  five  wounds :  (a)  an  extensive  wound  caused  by  a  shell- 
splinter,  involving  the  posterior  external  portion  of  the  left 
lower  leg  with  fracture  of  the  fibula ;  (b)  a  wound  caused 
by  a  shell-splinter,  very  deep,  in  the  middle  portion  of  the 
left  thigh  ;  (c)  a  penetrating  wound  caused  by  a  bullet,  in 
the  left  forearm ;  (</)  a  penetrating  bullet-wound  in  the 
right  ankle ;  (e)  a  penetrating  bullet-wound  above  the  left 
external  malleolus.      He  was  also  suffering  from  dysentery. 

Picked  up  by  the  Germans,  on  the    10th   September,  at 


OBSERVATIONS  771 

6  in  the  afternoon,  and  taken  by  them  to  the  hospital  at 
Saint-Andre^  the  first  dressings  were  applied  there.  Left 
behind  when  the  enemy  retreated,  on  the  evening  of  the 
12th  September,  he  was  carried  into  the  French  lines  on 
the  13th,  owing  to  the  care  of  a  French  surgeon,  a  prisoner 
like  himself.  The  second  dressings  were  applied  on  the 
14th  September,  at  the  Rambluzin  field  hospital.  Taken 
to  the  Radepont  railway  station,  and  placed  in  an  ambulance 
train,  he  reached  the  Bar-sur-Aube  hospital  at  10  o'clock 
at  night.  There  an  injection  of  antitetanic  serum  was 
administered  the  same  night. 

He  was  treated  at  the  Bar-sur-Aube  hospital  from  the 
15th  September  to  the  18th  December.  He  left  it  almost 
cured,  one  of  his  wounds  still  requiring  attention,  while 
the  dysentery  was  only  ameliorated ;  he  walked  with  diffi- 
culty. For  these  various  reasons  he  entered  Auxiliary 
Hospital  102,  18  rue  Charles-Oivry,  Paris,  where  I  attended 
him. 

He  told  me  that  six  weeks  after  entering  the  Bar-sur-Aube 
hospital  he  was  afflicted  by  a  difficulty  in  opening  the  jaws, 
with  acute  pains  in  the  region  of  the  ternporo-maxillary 
articulation.  A  few  days  later  similar  pains  appeared  in  the 
neck,  accompanied  by  a  sensation  of  "stiffening"  (this  was 
the  word  used  by  the  patient  himself)  in  the  muscles  of  that 
region.  When  I  saw  him  for  the  first  time  these  phenomena 
had  diminished  in  the  ternporo-maxillary  region.  The  jaws 
opened-almost  normally,  but  when  the  man  spoke  the  pains 
recurred  for  the  moment  in  the  region  of  the  jaws.  In  the 
back  of  the  neck  the  pains  and  contractures  were  severe 
and  permanent.  From  time  to  time  there  was  an  exacer- 
bation of  these  phenomena,  and  one  could  then  feel  the 
contracture  of  the  muscles  under  the  hand  ;  they  became 
of  a  woody  hardness.  When  these  paroxysms  occurred  the 
patient  was  obliged  to  lie  down,  or  at  least  to  seat  himself 
in  a  reclining  chair.  The  pains  frequently  descended  below 
the  shoulders,  along  the  vertebral  column.  The  paroxysms 
were  most  frequent  during  the  night  and  in  bed. 

At  this  stage  I  diagnosed  the  affection  as  late  tetanus,  but 
considering  that  these  late  forms  could  not  possibly  be  serious, 
I  instituted  no  further  treatment  than  sedative  frictions  with 
alcohol  in  the  regions  affected.  The  phenomena  gradually 
disappeared.     When    the    patient    left    the    hospital,    being 


772      THE  ABNORMAL  FORMS  OF  TETANUS 

temporarily  discharged  from  service,  he  was  suffering  only 
from  very  slight  occasional  spasms,  which  occurred  at  very 
long  intervals.  These  ceased  entirely  a  short  time  after  he 
left  the  hospital.  The  dysentery  yielded  to  a  treatment, 
which  was  principally  dietetic,  only  eight  or  ten  days  before 
he  left.  At  the  present  time  the  patient  is  in  good  condi- 
tion, although  he  still  has  a  certain  difficulty  in  walking  and 
an  eversion  of  the  left  foot,  with  a  tendency  to  touch  the 
ground  only  along  its  outer  edge. 

Observation   XIV.   (M.  H.  Bouctuet).— Late-appearing 
localised  tetanus 

Louis  R ,  of  the  1st  mixed  Regiment  of  Sharpshooters 

and  Zouaves,  entered  Auxiliary  Hospital  No.  102  on  the 
29th  October  1915.  Wounded  on  the  6th  October  1915  at 
Ferme-de-Champagne.  Having  received  the  preventive 
injection  of  antitetanic  serum  on  the  7th  October,  he  was 
first  under  treatment  in  the  hospital  at  Revigny,  before  enter- 
ing our  sanitary  formation. 

The  wounds  were  on  a  fair  way  to  be  healed  when,  on  the 
19th  December  1915,  the  wounded  man  was  attacked,  at 
intervals  of  a  few  hours,  by  three  tetaniform  paroxysms.  He 
was  suddenly  attacked  by  violent  pains  in  the  epigastric 
region,  the  head  being  slightly  retroverted.  The  face  was 
grimacing  ;  there  was,  however,  no  trismus,  but  if  one  placed 
the  hand  on  the  abdomen  one  felt  the  forcible  contracture  of 
the  rectus,  which  was  veritably  tetanised.  The  first  attack 
left  my  diagnosis  in  abeyance.  At  the  second  I  suspected 
delayed  tetanus,  and  administered  a  subcutaneous  injection 
of  10  c.c.  of  antitetanic  serum.  Thereupon,  on  account  of 
the  regulations  in  force,  I  was  obliged  to  send  my  patient  to 
the  special  department  for  contagious  cases.  He  was  there- 
fore admitted  to  the  hospital  in  the  Lycee  Buffon,  whek*e  we 
learned  recently  that  the  patient  had  recovered,  and  that  he 
had  been  given  intravenous  injections  of  antitetanic  serum. 

Observation  XV.  (Mdriel). — Tetanus  localised  in  the  lower 

limb 

« 

Julian    L ,  of  the   342nd   Regiment  of  Infantry,   was 

wounded  on  the  28th  September  1915  at  Virginy,  by  shell- 


OBSERVATIONS  773 

splinters.  The  first  dressing  was  applied  on  the  spot,  an  hour 
later.  The  second  was  applied  at  the  field  hospital,  where 
an  antitetanic  injection  was  administered. 

The  patient  arrived  at  Foix  (Hospital  No.  l)  on  the  3rd 
October.  He  presented  a  superficial  wound  of  the  left  frontal 
region,  a  perforating  wound  in  the  upper  third  of  the  left 
thigh,  and  another  wound  of  the  same  nature  in  the  lower 
third  of  the  left  lower  leg. 

On  the  8th  October,  in  the  evening,  the  wounded  man  began 
to  feel  pains  in  the  left  lower  limb.  The  wounds  had  a  good 
appearance.     No  temperature. 

On  the  9th  October  sudden  and  involuntary  contractions 
were  noted  in  the  left  lower  limb,  which  were  at  once  ex- 
aggerated if  the  patient  was  touched.  The  other  limbs  were 
unaffected.  No  trismus;  no  stiffness  of  the  neck.  Tempera- 
ture, 100-8°  F.  ;  pulse,  102.     An  agitated  night. 

On  the  10th,  the  tetaniform  symptoms  persisting,  with  a 
temperature  of  100'4  °  F.,  an  injection  of  10  c.c.  of  antitetanic 
serum  was  given. 

On  the  11th,  a  fresh  injection  of  antitetanic  serum  and  a 
dose  of  2  grammes  of  chloral  per  rectum.  The  patient  was 
isolated.  In  the  evening  the  contractions,  localised  still 
exclusively  in  the  left  leg,  returned  in  paroxysms,  which 
were  extremely  painful,  preventing  all  sleep,  and  finally 
necessitating  an  injection  of  morphia. 

On  the  12th,  13th,  14th,  and  15th  the  condition  remained 
stationary,  and  an  injection  of  5  c.c.  was  repeated  daily. 
The  chloral  and  morphia  were  also  continued. 

On  the  15th,  however,  the  contractions  diminished  slightly, 
but  a  contracture  appeared,  particularly  accentuated  in  the 
muscles  of  the  buttock  and  the  posterior  portion  of  the  thigh. 
The  patient  also  complained  of  violent  pains,  and  cried  out, 
especially  at  night.  He  was  accordingly  given  three  doses  of 
chloral  per  rectum  daily,  and  an  injection  of  morphia  about 
9  o'clock  at  night. 

During  the  five  following  days  an  attempt  was  made  to 
discontinue  the  antitetanic  injections,  but  the  contractures 
and  pains  became  more  violent.  The  injections  were  there- 
fore resumed  on  the  21st,  and  continued  daily  until  the  26th, 
the  dose  being  5  c.c.  on  each  occasion. 

To  break  the  patient  off  his  daily  injection  of  morphia  an 
attempt   was  made  to  replace  it  by  a  draught  containing 


774    te:e  abnormal  forms  of  tetanus 

syrup  of  morphine.  None  the  less  he  continued  to  complain 
all  night ;  he  passed  urine  in  the  bed ;  he  was  delirious,  and 
his  appearance  was  quite  abnormal. 

The  contractions  tended  progressively  to  disappear ;  but 
the  contracture  persisted.  Between  the  28th  October  and 
the  2nd  November  only  one  injection  of  5  c.c.  of  antitetanic 
serum  was  given  every  second  day. 

From  the  4th  to  the  19th  of  November  an  injection  was 
given  only  every  third  day ;  from  the  22nd  November  to 
the  3rd  December  every  fourth  day ;  and  from  the  3rd 
December  to  the  17th  every  fifth  day.  At  the  same  time  the 
dose  of  chloral  was  gradually  diminished  :  from  15  grammes 
it  was  reduced  to  5  grammes  in  the  24  hours;  first  one,  and 
then  two  doses  were  suppressed  each  day ;  and  on  the  20th 
of  December  the  drug  was  entirely  discontinued. 

At  the  same  time  the  dose  of  morphia  was  gradually 
diminished,  until  it  was  discontinued  on  the  25th  December. 

The  tetanic  symptoms  localised  in  the  left  lower  limb 
became  slowly  attenuated.  The  lower  leg,  which  had  for 
a  long  time  remained  flexed  at  right  angles  to  the  thigh, 
gradually  extended  itself,  and  the  contracture  disappeared. 
The  toes,  at  first  contracted  like  talons,  gradually  assumed 
their  normal  position  and,  movements. 

The  wounds,  which  had  suppurated  abundantly  while  the 
tetanic  paroxysms  were  still  occurring,  were  now  healed. 

At  the  beginning  of  January  the  patient  was  able  to  get  up 
and  walk,  still  dragging  the  leg  slightly.  The  general  con- 
dition was  excellent.  At  the  present  moment  (20th  January) 
he  is  restored  to  health. 

There  was  no  hysteria  in  the  patient's  antecedents.  It 
should  be  remarked,  however,  that  there  was  a  certain  degree 
of  alcoholism,  the  patient  having  been  carter  to  a  wholesale 
wine  merchant,  and  accustomed  to  drinking  5  litres  of  wine 
per  diem. 

Observation  XVI.  (Personal) 

C ,  twenty-eight  years  of  age,  a  second  lieutenant,  was 

wounded  in  Champagne,  at  Jonchery,  on  the  25th  September, 
by  splinters  of  a  grenade,  which  occasioned  three  wounds  in 
the  left  thigh.  He  received  his  first  dressing  on  the  same 
day,  about  two  hours  after  the  wound,  at  the  field  ambulance. 


OBSERVATIONS  775 

A   temporary   dressing  was   applied,  after   the  wounds   had 
been  disinfected  with  tincture  of  iodine. 

The  same  evening  the  wounded  man  was  evacuated  into 
the  Cupperly  field  hospital,  and  on  the  following  evening — 
that  is,  on  the  26th  September — about  ten  o'clock,  one  of  the 
projectiles  was  extracted,  which  was  causing  violent  pain, 
owing  to  its  superficial  position  on  the  internal  and  posterior 
region  of  the  thigh,  it  having  traversed  the  anterior  face  of 
the  member  about  the  middle  portion  of  Scarpa's  triangle. 

This  projectile  was  discovered  at  a  depth  of  about  two-fifths 
of  an  inch,  and,  according  to  the  information  furnished  by  the 
patient,  it  was  about  the  size  of  a  hazel-nut.  The  two  other 
wounds  were  disinfected  ;  one  being  at  the  base  of  Scarpa's 
triangle,  near  the  outer  edge,  and  about  four-fifths  of  an  inch 
in  length,  while  the  other,  which  was  smaller,  was  on  the 
external  face  of  the  thigh,  about  four-fifths  of  an  inch  from 
the  great  trochanter. 

After  the  dressing  a  preventive  injection  of  10  c.c.  of 
antitetanic  serum  was  given ;  this  was  on  the  day  after  the 
wound. 

On  the  28th  September  the  patient  left  the  hospital  at 
the  front  and  was  sent  to  Paris,  where  he  arrived  on  the 
morning  of  the  29th.  He  was  admitted  to  Temporary 
Hospital  No.  60. 

In  this  hospital  the  wounds  were  dressed  daily.  A  radio- 
graphic examination  revealed  the  presence  of  two  large 
grenade-splinters,  about  the  same  size  as  that  which  had 
been  extracted,  one  being  situated  in  the  internal  and  superior 
portion  of  the  thigh  and  the  other  in  the  superior  and 
external  portion. 

A  little  lower  the  presence  of  five  or  six  other  small  splinters 
was  noted.  The  wounds  were  suppurating  profusely.  The 
pain  in  the  region  of  the  wounds  was  not  very  marked.  The 
general  condition  remained  good,  and  the  rectal  temperature 
was  normal. 

On  account  of  the  situation  of  the  projectiles,  and  also  the 
appearance  of  muscular  contractions,  the  patient  was  evacu- 
ated, on  the  21st  October,  to  the  clinic  in  the  Rue  Bizet, 
under  the  direction  of  Dr  Gosset.  There  the  splinters  were 
localised  by  means  of  the  Bergonie  apparatus,  and  Dr  Gosset 
thought  it  best  to  send  the  patient  to  the  Hopital  Buffon,  on 
the  23rd  October. 


776       THE  ABNORMAL  FORMS  OF  TETANUS 

At  this  date  the  patient  stated  that  ten  days  after  he  was 
wounded,  while  he  was  in  Temporary  Hospital  No.  60,  muscular 
contractions  appeared  on  the  inner  face  of  the  left  knee, 
which  were  of  short  duration  (two  or  three  seconds)  but  ex- 
tremely painful.  They  recurred  about  once  in  two  minutes. 
These  contractions  increased  day  by  day,  progressively,  in 
severity  and  in  frequency,  while  at  the  same  time  they  became 
more  painful.  There  was  no  contracture  or  cramp  in  any 
other  part  of  the  body,  no  trismus,  and  the  temperature  was 
normal. 

About  the  fifth  day—  that  is,  fifteen  days  after  he  was 
wounded — there  was  a  remission  for  24  hours,  marked 
by  less  violent  and  less  frequent  pains  and  contrac- 
tions, these  recurring  only  about  once  in  five  minutes.  The 
wounded  man  even  felt  that  he  was  in  a  fair  way  toward 
recovery.  But  on  the  following  day  the  convulsive  jerks 
reappeared,  more  marked  than  before,  and  extremely  painful. 
They  were  then  recurring  three  or  four  times  a  minute,  and 
lasted  two  or  three  seconds. 

The  absence  of  trismus  was  still  noted,  and  there  was 
no  temperature.  The  patient  was  able  to  take  his  food 
normally. 

Upon  his  entering  our  hospital,  on  the  21st  October,  the 
patient  appeared  to  us  to  be  greatly  fatigued  and  anxious. 
He  complained  of  having  had  no  sleep  since  the  5th  October. 
On  examining  him  we  were  immediately  struck  by  the  clonic 
contractions  involving  the  entire  musculature  of  the  wounded 
thigh.  At  the  same  time  the  patient  complained  of  excruciat- 
ing pains  during  the  paroxysms.  The  convulsive  jerks  were 
recurring  three  or  four  times  a  minute.  There  were  no 
longer  any  remissions,  and  the  contractions  were  localised  in 
the  upper  portion  of  the  left  thigh.  No  trismus  was  observed, 
nor  any  contractures  or  pain  in  the  right  leg.  But  the  left 
lower  limb  was  contractured,  the  lower  leg  being  lightly 
flexed  upon  the  thigh  and  the  thigh  upon  the  pelvis. 

The  temperature  was  not  very  high :  99*7°  F.  in  the 
evening. 

A  subcutaneous  injection  of  30  c.c.  of  antitetanic  serum 
was  given  this  day  (21st  October). 

22nd  October. — The  patient  was  still  in  the  same  condition, 
complaining  of  extremely  violent  pains.  He  was  greatly 
agitated. 


OBSERVATIONS  777 

The  contractions  remained  localised  in  the  left  thigh. 

The  temperature,  in  the  morning,  was  ^^'^°  F.  ;  in  the 
evening,  99-7°  F. 

This  day  a  certain  constraint  was  noted  in  the  temporo- 
maxillary  articulation,  although  there  was  not  as  yet,  properly 
speaking,  any  trismus. 

9.5th  October. — The  muscular  jerks  were  still  very  frequent 
and  very  painful.  At  the  same  time,  a  fairly  well  defined 
trismus  was  noted  in  the  morning,  rendering  alimentation 
difficult.  The  wounds  were  suppurating  profusely,  and,  con- 
sidering the  general  condition  of  the  patient,  the  surgeon's 
intervention  was  requested ;  it  was  hoped  that  the  nervous 
symptoms  might  thereby  be  arrested. 

The  temperature  was  still  almost  normal:  98*9°  F.  in  the 
morning,  and  99'1°  F.  in  the  evening. 

Dr  Berger  operated.  After  making  a  vertical  incision  in  the 
Scarpa's  triangle  of  the  left  thigh,  and  having  penetrated 
the  cribriform  fascia,  the  surgeon  removed  a  foreign  body 
which  was  situated  inside  the  sheath  of  the  blood-vessels  in 
contact  with  the  femoral  vein. 

Dr  Berger  made  a  second  incision  in  the  superior  and 
external  portion  of  the  thigh,  penetrating  the  fascia  lata,  and 
removed  a  foreign  body. 

A  third  foreign  body  was  quivering  behind  the  blood- 
vessels, but  was  deeply  buried ;  the  surgeon  decided  not  to 
attempt  its  removal. 

An  injection  of  5  c.c.  of  antitetanic  serum  was  made  in 
each  wound,  and  another  of  10  c.c.  in  the  femoral  sheath, 
over  the  crural  nerve. 

Dressing. 

An  injection  of  I  centigramme  of  morphia  was  given  also, 
and  the  patient  absorbed  20  grammes  of  chloral. 

9,Mh  October. — Morning  temperature,  100*7°  F. ;  evening 
temperature,  102-1°  F.     Pulse,  100. 

Milk  diet.  Injection  of  S5  c.c.  of  serum.  Chloral,  20 
grammes.     Morphia,  2  centigrammes. 

The  local  condition  was  practically  the  same  ^  the  day 
before.  The  convulsive  jerks  were  as  frequent,  as  painful, 
and  of  the  same  duration.  *  Trismus  worse. 

9oth  October. — Temperature,  100*7°  ;  pulse,  94.  Urine, 
400  c.c.  Subcutaneous  injection  of  40  c.c.  of  serum.  Chloral. 
15  grammes;  morjphia,  2  centigrammes.     Same  condition. 


778       THE  ABNORMAL  FORMS  OF  TETANUS 

26th  October. — Temperature,  100°.  Pulse,  88.  Urine, 
600  c.c. 

An  injection  of  60  c.c.  of  serum.     Chloral,  12  grammes. 

No  perceptible  amelioration. 

27tk  October.— TempersLture,  100-1°,  102-9°  F.  Pulse,  120. 
Urine,  200  c.c. 

An  injection  of  40  c.c.  of  serum.  Chloral,  4  grammes. 
Morphia,  2  centigrammes. 

28ih  October.— Temperature,  104°,  103-6°  F.  Pulse,  108. 
Urine,  700  c.c. 

Despite  a  very  marked  seric  reaction,  10  c.c.  of  serum  was 
injected.  Chloral,  6  grammes.  Delirium.  The  muscular 
contractions  still  persisted,  frequent  and  extremely  painful. 
On  examination  no  further  localisation  of  the  contractures 
was  observed. 

29th  Oc/o6e/-. -^Temperature,  100*4°,  100-8°  F.  Pulse,  100, 
120.  Urine,  200  c.c.  Injection  of  30  c.c.  of  antitetanic 
serum.     Chloral,  8  grammes. 

30th  October.— Temperature,  100-4°,  101-5°.  Pulse,  114. 
Urine,  2000  c.c. 

Injection  of  20  c.c.  of  serum.     Chloral,  6  grammes. 

31st  October.— Temperature,  101-1°,  100-4°  F.  Pulse,  96. 
Urine,  1500  c.c.  Subcutaneous  injection  of  10  c.c.  of  serum  ; 
chloral,  6  grammes. 

1st  November.— Temperature,  100-7°,  100°  F.  Pulse,  112. 
Urine,  1700  c.c.     Injection  of  10  c.c.  of  serum. 

2nd  November.— Temperature,  9.93°,  98*9°  F.  Pulse,  92. 
Urine,  1500  c.c.  General  condition  improved;  but  the  con- 
tractions were  still  very  frequent. 

3rd  November. — Injection  of  10  c.c.  of  serum. 

5th  November. — Injection  of  10  c.c.  of  serum.  Chloral,  3 
grammes. 

From  this  date  the  contractions  diminished  in  frequency 
and  duration,  and  a  progressive  improvement  was  noted 
day  by  day,  until  on  the  12th  November  the  convulsive 
contractions  disappeared. 

On  the  9th  November  a  further  injection  of  20  c.c.  of 
serum  was  given,  and  on  the  1 1th  an  injection  of  10  c.c. 

Recovery  seemed  complete  until  the  20th  November,  on 
which  day  the  patient  exhibited  a  slight  rise  of  temperature 
and  a  slight  difficulty  in  mastication,  without  any  further 
signs  of  contracture.     On  the  following  day,  after  an  in- 


OBSERVATIONS  779 

jection  of  20  c.c.  of  serum,  all  became  normal  once  more, 
and  the  patient  felt  extremely  well. 

The  wounds  had  cicatrised  about  six  days  earlier. 

Isf  December. — The  patient  exhibited  merely  a  functional 
difficulty  in  using  the  left  leg.  This  limb  exhibited  a  per- 
sistent stiffness :  the  movements  of  the  hip-joint  were  very 
free,  but  in  the  knee,  on  the  other  hand,  there  was  an 
obvious  constraint.  The  movements  of  flexion  were  limited. 
In  the  tibio-tarsial  articulation  the  derangement  was  still 
more  marked ;  the  movements  of  the  foot  were  almost 
impossible.  The  leg  was  in  extension.  The  foot  was  in 
external  rotation,  with  a  tendency  to  talipes  equinus.  There 
was  a  very  marked  retraction  of  the  tendon  of  Achilles,  and 
a  slight  muscular  atrophy  could  be  noted  on  the  side 
affected. 

Examination  of  Rejiexes. — Percussion  of  the  patellar  tendon 
provoked  a  tonic  contraction  of  the  quadriceps  on  the 
affected  side. 

There  was  exaggeration  of  the  patellar  reflex  with  clonus 
of  the  patella.  The  Achilles  tendon  reflex  was  normal. 
Babinski's  sign  was  negative.  There  was  no  exaggeration 
of  the  defensive  reflexes,  and  no  indication  of  spinal  lesion. 

An  examination  of  the  electric  reactions  revealed  a 
notable  diminution  of  the  contractility  of  the  muscles  and 
nerves  of  the  affected  limb  when  stimulated  by  galvanic 
and  faradaic  currents. 

In  the  upper  limbs  the  reflexes  were  normal.  It  should 
be  noted  that  the  masseteric  reflex  was  exaggerated. 

Here,  then,  we  have  a  case  of  early  tetanus  localised  in 
the  left  leg. 


jj/; 


CHAPTER  II 

HISTORICAL 

Although  cases  such  as  those  described  are  excessively 
rare,  it  must  not,  therefore,  be  supposed  that  the 
locahsed  and  partial  forms  of  tetanus  escaped  the  atten- 
tion of  the  ancients.  Hippocrates  even,  in  respect  of 
tetanus,  indicated  three  forms  :  "  straight  "  tetanus, 
opisthotonos,  and  a  third  more  serious  form.  But 
Guy  de  Chauliac,  in  1363,  was  the  first  to  draw  the 
distinction  between  generalised  and  localised  tetanus. 

In  1772  Sauvages  described  the  chronic  form  of 
tetanus,  which  he  styled  Cathocus,  and  the  lateral  form, 
of  which,  according  to  Rose,  we  find  the  first  indication 
in  Sophocles. 

Larrey  distinguished  acute  and  chronic,  partial  and 
complete  tetanus,  and  recorded  examples  of  localised 
tetanus. 

Dupuytren  cited  a  case  of  tetanus  following  upon  a 
c(Hitused  wound  of  the  thenar  eminence  ;  the  wound 
had  healed  when  the  patient  experienced  extremely 
severe  pains  with  contracture  of  all  the  fingers. 
Similar  observations  were  placed  on  record  by  Remy, 
Annandale,  Gintrac,  Gross,  and  Heinke. 

Colles,  in  1852,  and  Follin,  in  1861,  distinguished 
between  the  true  general  tetanus  and  tetanoid  spasms 
confined  to  the  injured  member. 

Legouet  recorded  the  case  of  a  lad  of  fifteen  who  was 
attacked  by  localised  trismus  as  the  result  of  an  accident 

780 


HISTORICAL  781 

which  tore  off  the  third  phalange  of  the  forefinger, 
with  its  fiexor  tendon. 

In  1870  Richelot  recorded  the  case  of  a  wounded 
man  who  was  affected  by  a  partial  tetanus  which 
lasted  for  several  weeks.  Having  left  hospital  too 
soon,  the  patient  was  attacked  by  generalised  con- 
vulsions, and  succumbed  in  a  few  days. 

In  1883  Bond  observed  a  cephalic  tetanus  which  set 
in  on  the  twentieth  day,  and  a  similar  case  was  recorded 
by  Buisson  in  1888,  the  period  of  incubation  being 
twenty-two  days. 

In  1904  appeared  Demontmerot's  thesis  on  the 
paraplegic  form,  in  which  four  observations  were  re- 
corded. Esau,  in  1910,  published  the  details  of  a  case 
of  local  tetanus  of  the  hand.  But  as  we  have  already 
remarked,  in  the  majority  of  these  observations  the 
affection  described  is  not,  properly  speaking,  a  true 
partial  tetanus.  If  by  this  term  we  understand  an  in- 
fection by  Nicolai'er's  bacillus,  localised  in  a  determined 
anatomical  region,  and  not  proceeding  to  generalisa- 
tion, we  may  say  that  the  history  of  partial  tetanus  of 
the  limbs  is  of  recent  date.  We  have  seen  how  the 
observations  of  Esau,  Boinet  and  Monges,  and  Curtillet 
and  Lombard  should  be  regarded  ;  and  certain  observa- 
tions which  were  published  by  Demontmerot  in  his 
thesis  should  likewise  be  classified  as  cases  of  tetanus 
with  paraplegic  onset  rather  than  as  observations  of 
paraplegic  and  partial  tetanus,  for  after  a  transient 
and  initial  localisation  of  the  contractures  in  the  lower 
limbs,  trismus  appeared,  with  stiffness  of  the  neck  and 
trunk. 

We  may  therefore  consider,  in  accordance  with  the 
definition  which  we  have  given  of  local  tetanus — "an 
affection  which  is  local  during  its  entire  development  " 


783      TEE  ABNORMAL  FORMS  OF  TETANUS 

— ^that  observations  of  local  tetanus  of  the  limbs,  at  all 
events  of  the  monoplegic  form,  have  not  long  been 
known. 

In  May,  1915,  appeared  the  first  report  of  a  case  of 
local  tetanus  of  one  leg,  in  a  work  of  Courtellemont's. 

Then,  in  June,  1915,  Albert  ^Ramirez  Martinez  repro- 
duced in  his  thesis  a  very  instructive  observation  by 
Professors  Rauzier  and  Estor.  This  was  of  a  late- 
appearing  localised  tetanus,  the  seat  of  which  was  one 
of  the  lower  limbs. 

Then  Pozzi,  from  the  tribune  of  the  Academy  of 
Medicine,  in  November,  1915,  described  a  typical 
example  of  early  local  tetanus  of  the  limbs.  The 
localisation  was  in  the  first  place  monoplegic,  then, 
temporarily,  paraplegic,  but  with  a  marked  pre- 
dominance in  the  wounded  leg.  It  persisted  for  five 
weeks,  and  was  followed  by  recovery. 

This  observation,  the  first  of  this  rare  clinical  type, 
evoked,  by  its  interest,  the  publications  of  Monod, 
Routier,  Laval,  Carnot,  Courtois-Suffit  and  Rene 
Giroux,  and  Meriel.  Now  that  these  cases  are  better 
known,  they  have  become  less  rare.  At  the  present  time 
numerous  cases  have  been  recorded,  and  Dr  Fricker,  in 
connection  with  a  certain  number  of  personal  observa- 
tions, has  lately  reviewed  the  question  of  the  partial 
forms  of  tetanus  in  his  inaugural  thesis.^ 

In  the  following  pages  we  shall  describe  the  peculiar 
symptoms  and  the  special  evolution  of  this  local  and 
atypical  form  of  the  tetanus. 

^  Unfortunately  we  have  not  been  able  to  consult  this  thesis;  we 
feel,  however,  under  an  obligation  to  mention  it,  in  order  that  the 
reader  may  consult  the  observations  recorded  by  this  writer. 


CHAPTER  III 

MONOPLEGIC  FORM 

1.  Period  of  Incubation. — The  period  of  incubation  is 
the  interval  of  time  which  elapses  between  the  moment 
of  infection  and  the  moment  at  which  the  first  tetanic 
symptoms  appear.  Generally  speaking,  inoculation 
with  the  bacillus  gives  rise  to  no  immediate  sign.  No 
local  or  general  phenomena  reveal  the  multiplication 
of  Nicolaier's  bacilli,  nor  the  progressive  invasion  of 
the  system  by  the  toxin. 

Here  we  have  an  insidious  phase,  during  which  the 
tetanic  infection  is  developing,  although  no thmg  enables 
us  to  de1;ect  it. 

This  insidious  phase  is  of  very  variable  duration. 
It  may  be  brief  or  prolonged,  so  that  there  are  two 
distinct  forms  of  tetanus,  distinct,  at  least,  as  far  as 
the  appearance  of  the  first  tetanic  manifestations  is 
concerned.    These  are : 

1.  Early  or  precocious  local  tetanus. 

2.  Late-appearing  local  tetanus. 

In  the  first  variety  the  incubation  period  is  in  general 
of  brief  duration,  the  first  symptoms  usually  appearing 
between  the  fifth  and  tenth  day.  This  was  the  case  with 
the  observations  recorded  by  Pozzi  (fifth  day),  Laval 
(eighth  and  ninth  days),  and  ourselves  (tenth  day).  In 
this  connection,  whenever  the  first  signs  of  tetanus  ap- 
pear during  the  fortnight  following  the  wound,  we  regard 
the  disease  as  being  of  the  early  or  precocious  form. 

783 


784     TEE  ABNORMAL  FORMS  OF  TETANUS 

In  the  second  variety,  the  late-appearing  form  of 
locaUsed  tetanus,  the  period  of  incubation  is  always 
lengthy,  sometimes  extremely  lengthy.  This,  by  the 
\Vay,  is  one  of  the  most  important  characteristics  of 
this  form. 

Generally  speaking,  the  first  clinical  indications  of 
the  late  form  of  local  tetanus  appear  from  twenty  to 
thirty  days  after  the  wound,  when  the  latter  is  becoming 
cicatrised,  or  is  already  completely  cicatrised.  Some- 
times this  lapse  of  time  is  even  greater. 

Demontmerot  has  recorded  a  case  in  which  the  first 
symptoms  did  not  appear  until  six  weeks  after  the 
infliction  of  the  wound.  In  Rauzier  and  Estor's  case 
the  period  of  incubation  was  three  months.  Finally,  it 
must  be  mentioned  that  Huntington  has  cited  a  case  in 
which  tetanus  appeared  seven  months  after  the  wound, 
the  latter  being  still  discharging.  This  long  incubation 
in  the  late-appearing  form  is  often,  however,  apparent 
only.  Berard  and  Lumiere  have,  in  fact,  demonstrated 
that  this  variety  often  develops  as  the  result  of  a 
surgical  traumatism,  appearing  six,  eight,  ten,  or  fifteen 
days  after  operative  intervention,  which  usually  takes 
the  form  of  a  tardy  cleaning  out,  the  search  for  a  foreign 
body,  or  a  secondary  amputation,  sometimes — indeed, 
as  a  rule — involving  the  region  of  the  wound,  and  some- 
times a  region  remote  from  the  wound.  It  seems  logical 
to  accept  the  period  which  elapses  between  the  surgical 
traumatism  and  the  appearance  of  the  first  signs  of 
confirmed  tetanus  as  constituting  the  actual  period  of 
incubation.  The  spores  have  hitherto  remained  in  a 
condition  of  latent  vitality,  enclosed  in  a  crevice  which 
isolates  them  for  the  time  being,  or  encysted  in  a  shell 
of  inflammatory  tissue.  By  an  exploration  or  surgical 
operation  of  some  sort  these  spores  are  set  free,  sowing 


MONOPLEGIC  FORM  785 

themselves  in  the  adjacent  tissues  and  secreting  their 
toxins  there.  These,  therefore,  are  cases  of  secondary 
reinfection,  due  to  tardy  surgical  interventicm. 

The  development  of  these  late-appearing  forms  of 
tetanus  permits  us  to  refer  them  to  latent -mierobic 
infection  due  to  the  mechanical  liberation  of  the  spores, 
analogous  to  that  of  postponed  infection.  This  has 
been  demonstrated  experimentally  by  Tarozzi,  Canfora, 
and  Vincent,  who,  after  injecting  cultures  of  Nicolaier's 
bacillus  into  the  veins,  or  even  under  the  skin,  have 
found  spores  in  the  viscera  of  the  animals  experimented 
upon  several  weeks  after  injection.  They  have  shown 
that  a  traumatism,  or  anv  factor  which  diminishes  the 
resistance  of  the  organism,  as  cold,  for  example,  may 
result  in  an  outbreak  of  delayed  infection. 

On  other  occasions  the  surgical  traumatism  does  not 
give  rise* to  tetanus,  bui  accelerates  the  development  of 
tetanus  in  incubation.  Thus  in  the  cases  recorded  by 
Vallette  and  Leriche  tetanus  made  its  appearance  thirty- 
seven  and  forty-two  days  after  the  wound,  and  only 
twenty-four  to  forty-eight  hours  after  operation.  This 
lapse  of  time  is  too  short  to  be  regarded  as  a  period  of 
incubation. 

From  these  considerations  it  results  that  it  is  often 
difficult  to  form  an  approximate  estimate  of  the  period 
of  incubation  in  the  late-appearing  forms,  but  it  always 
exceeds  twenty  days.  This  ])eriod  of  at  least  twenty 
days  should  indeed  be  regarded  as  the  minimum  incuba- 
tion period  in  the  late-appearing  forms  of  localised 
tetanus. 

2.  Period  o!  Onset. — Whether  the  form  in  question 
is  early  or  late-appearing,  the  earliest  symptoms  are 
assuredly  those  which   it  is  most  important  to  under- 


786     THE  ABNOBMAL  FORMS  OF  TETANUS 

stand,  for  it  is  a  matter  of  urgency  that  an  early  diag- 
nosis should  be  established,  in  order  that  tetanus 
patients  may  be  treated  from  the  commencement  of 
the  infection. 

The  first  symptoms  are  often  unnoticed  if  one  is  not 
careful  to  interrogate  and  examine  the  patient  with  the 
greatest  care.  If  the  patient  does  not  complain  of  them 
these  first  indications  may  be  regarded  as  unimportant 
by  a  physician  who  is  not  on  the  watch  for  them,  so 
that  it  is  important  to  insist  upon  the  first  manifesta- 
tions of  the  onset  of  localised  tetanus. 

Prodromal  signs  of  a  local  or  general  character  may 
be  noted. 

Local  Signs. — ^In  the  region  of  the  wound,  which  may 
be  superficial — this,  according  to  some  writers,  explain- 
ing the  benign  character  of  certain  cases — we  may  note 
an  arrest  of  fleshy  vegetation,  or  of  suppuration,  or 
swelling,  with  redness  of  the  skin  and  mortification. 

More  significant,  and  more  constant,  are  shooting 
pains  in  the  region  of  the  wound,  and  spasms  in  the 
neighbouring  muscles,  followed  by  cramps  and  jerks 
or  twitchings. 

But  we  must  at  once  observe  that  such  local  pro- 
dromal phenomena  as  spasms  are  exceptional  in  the 
late  form  of  localised  tetanus,  which  usually  declares 
itself  at  a  period  when  the  wound  is  cicatrised,  so  that 
it  might  be  described  as  cicatricial  tetanus. 

The  pains  most  commonly  appear  in  the  affected 
limb,  but  this  is  not  invariably  the  case  ;  thus  to  cite 
a  typical  example,  in  the  case  recorded  in  Observation 
V.  the  wound  was  situated  in  the  right-hand  posterior 
scapular  region,  while  the  pains  and  contractures  first 
appeared  in  the  right-hand  lower  limb. 

The  patient  experiences  a  slight  sensation  of  contrac- 


MONOPLEGIC  FORM  787 

tion  in  the  affected  limb,  and  pain,  presently  followed 
by  a  sudden  and  involuntary  contraction  of  certain 
muscles. 

A  sudden  pain,  localised  in  one  limb,  without  apparent 
cause,  is  an  important  indication  in  a  wounded  man, 
and  the  occurrence  of  pain  should  always  arouse  atten- 
tion and  suggest  the  possibility  of  a  tetanic  outbreak. 

The  pain  in  question  may  be  fugitive,  giving  rise  to  a 
sudden  movement,  or  a  rheumatismal  pain,  or  there 
may  be  stiffness  in  the  wounded  limb.  In  addition  to 
pains  in  the  region  of  the  wound,  a  slight  feeling  of 
fatigue  in  the  jaws  is  sometimes  observed. 

This  pain  is  presently  followed  by  contracture  in  the 
same  region.  It  must  be  remembered  that  local  cramps 
occasionally  precede  trismus  even  in  the  normal  and 
generalised  forms  of  tetanus  ;  so  that  in  order  to  estab- 
lish an  early  diagnosis  the  physician  should  never 
await  the  appearance  of  trismus,  which  in  the  localised 
forms  is  always  transient. 

Foreign  writers  have  also  insisted  upon  the  occurrence 
of  cramps  at  the  outset  in  their  recent  dissertations 
(1914-1915)  upon  tetanus. 

The  essential  characteristic  of  the  cramps  is  that 
they  are  caused  more  particularly  by  external  excitation. 
A  cry  uttered  in  the  room,  the  sudden  closing  or  opening 
of  a  door,  the  sudden  switching  on  of  the  electric  light, 
the  fall  of  any  object,  the  noisy  tread  of  an  orderly, 
the  touch  of  cold  hands — all  these  incidents  may  pro- 
voke the  appearance  of  cramp. 

When  the  patient  himself  complains  that  these  con- 
tractures result  from  external  excitation,  there  is  no 
further  room  for  doubt :  the  patient  is  certainly  suffer- 
ing from  tetanus. 

The  cramps  often  attack  certain  groups  of  muscles, 


788     THE  ABNORMAL  FORMS  OF  TMTANUS 

and  Confine  themselves  to  these  during  the  whole 
course  of  the  malady  ;  or  they  may  spread  over  the 
whole  of  a  liinb.  The  contracture  is  total  or  partial, 
and  in  this  latter  case  one  segment  of  the  limb  may 
escape  it.  This  was  the  case  in  two  of  the  observations 
published  by  Routiep:  the  hand,  in  the  case  of  one  of 
his  patients,  remained  free,  with  a  contractured  upper 
arm  and  forearm  ;  in  the  other  case  the  lower  leg  and 
thigh  were  rigid,  but  the  foot  remained  mobile.  In 
the  case  observed  by  the  present  writers  the  contrac- 
tures were  strictly  localised  in  the  left  thigh.  It  must 
also  be  remembered  that  the  initial  seat  of  the  con- 
tractures, or  of  the  symptomatic  pains,  may  be  fax 
removed  from  the  point  of  inoculation.  In  certain 
cases,  which  are,  however,  rare,  t}ie  contracture 
may  occur  in  the  muscles  of  the  jaw,  but  this  symptom 
is  always  slight  and  ephemeral.  It  amounts  merely 
to  a  certain  difficulty  in  opening  the  mouth ;  the 
patient  can  eat,  drink,  and  speak  normally. 

It  must  also  be  remembered  that  at  the  very  be- 
ginning the  patient  may  exhibit  merely  a  slight  stiffness, 
which  does  not  prevent  his  walking.  In  certain  cases 
the  physician  himself  discovers  this  stiffness  on  the 
occasion  of  an  examination  or  a  dressing. 

As  Montais  remarks,  this  slight  stiffness  may  be 
brought  to  light  by  attempts  to  reduce  it,  by  voluntary 
movements,  or  by  any  local  excitation.  Palpation 
reveals,  in  such  cases,  hypertonia  of  the  muscles  which 
contract  through  their  whole  extent  when  subjected  to 
any  excitation.  The  muscular  contraction  thus  pro- 
voked is  normally  extensive  and  prolonged,  and  per- 
ceptible to  the  patient ;  after  the  lapse  of  a  few  days 
it  is  only  too  evident. 

The  general  symptoms,  in  a  case  of  local  tetanus,  do 


MONOPLEGIC  FORM  789 

not  attract  the  attention  of  the  cUnician,  and,  above 
all,  are  less  significant  than  the  pains  and  cramps. 

The  general  prodromal  symptoms  are  headache, 
anorexia,  yawning,  lumbar  pains,  peculiar  sensitive- 
ness to  cold,  a  tendency  to  perspire,  disturbed  sleep, 
dysuria,  and  constipation. 

The  rise  of  temperature  is  very  irregular.  This  fact 
has  been  noted  by  all  those  writers  who  have  latterly 
treated  the  subject.  Sometimes  there  is  a  rise  of 
temperature  at  the  outset ;  sometimes  it  occurs  only 
after  the  lapse  of  two  or  three  days,  and  we  shall  see 
that  although  the  fever  sometimes  attains  104°  F.;  it 
is  more  usual  to  see  the  thermometer  mark  100-5°  to 
101-5°  F.,  so  that  the  examination  of  the  temperature 
does  not  as  a  rule  furnish  information  of  any  value. 

The  pulse  is  fairly  normal. 

On  the  other  hand,  the  change  of  expression  observed 
in  the  patient  is  an  indication  which  demands  our 
attention.  When  describing  the  attenuated  and  slowly 
developing  forms  of  tetanus  we  shall  see  that  Claude 
and  Lhermitte  have  laid  great  stress  upon  the  facial 
aspect  of  the  patient. 

In  the  localised  forms  one  is  struck  by  the  expression 
of  anxiety  of  the  countenance  during  the  whole  develop- 
ment of  the  disease  ;  an  anxiety  which  is  increased  by 
the  dread  of  sounds  and  movements,  and  which  dis- 
appears the  very  moment  the  pains  and  contractures 
cease. 

Lastly,  we  shall  call  attention  to  the  fact  that  from 
the  very  commencement  of  local  tetanus  there  is  ob- 
served, in  the  limb  which  is  the  seat  of  the  pains  and 
contractures,  a  certain  nervous  irritability  which  is 
revealed  by  an  exaggeration  of  the  reflexes,  which 
becomes  manifest  as  the  acute  phase  approaches. 


790       TEE  ABNORMAL  FORMS  OF  TETANUS 

To  sum  up.  The  mode  of  onset  of  local  tetanus  of 
the  limbs  is  almost  always  identical.  Although  there 
is  no  appreciable  cause,  although  neither  the  situation 
nor  the  nature  of  the  wound  give  rise  to  suspicion,  a 
pain  suddenly  occurs  in  one  limb,  usually  the  limb 
neighbouring  upon  or  containing  the  wound,  and  then 
contractures  make  their  appearance,  recurring  under 
the  stimulus  of  external  excitation.  The  temperature 
is  not  very  high,  but  the  patient's  facial  expression 
becomes  anxious.  It  is  as  though  he  were  aware  that 
the  tetanus  was  developing  toward  an  acute  stage. 

3.  Period  of  Acme. — During  the  period  of  acme  the 
signs  already  described — namely,  the  pains  and  con- 
tractures— attain  their  maximum  intensity  ;  and  it  is 
during  this  period  that  the  tetanic  infection  almost 
invariably  exhibits,  in  the  localised  forms,  ephemeral 
phenomena  of  generalisation.  These  phenomena, 
however,  cancel  none  of  the  characteristics  peculiar  to 
the  special  localisation  of  the  disease.  A  local  disease, 
it  remains  local,  despite  transient  trismus,  and  a  trace 
of  stiffness  in  the  neck,  despite  the  respiratory  troubles 
which  occur  in  certain  cases. 

These  localised  contractures  are  the  signs  which 
dominate  the  clinical  picture  :  contractures  which  are 
sometimes  accompanied  by  extremely  violent  pains, 
which  force  the  patient  to  cry  aloud.  They  are  some- 
times slight  and  tardy,  but  in  the  majority  of  cases 
they  are  severe  and  appear  early,  constituting  a  signi- 
ficant indication. 

The  pains  coincide  with  the  spasms.  Sometimes  they 
radiate  through  the  whole  of  the  wounded  limb,  some- 
times they  remain  localised  in  one  segment  of  the  limb. 
Sometimes  they  extend  even  further,  invading  other 


MONOPLEGIC  FORM  791 

regions  :  the  opposite  limb,  the  other  limb  on  the  same 
side,  the  abdomen,  etc. ;  or  they  may  be  confined  to  a 
determined  region.  Their  essential  characteristic  is 
that  their  severity  is  intensified  by  the  stimulus  of  the 
slightest  sound,  or  a  sudden  movement  in  the  neigh- 
bourhood of  the  patient's  bed. 

The  contractures  are  intense ;  they  may,  like  the  pains, 
become  generalised  throughout  the  entire  limb,  or  they 
maybe  confined  to  a  single  segment ;  often  enough  they 
ascend  as  far  as  the  abdominal  wall.  They  may  also 
sometimes  invade,  in  a  secondary  and  ephemeral  fashion, 
the  opposite  limb,  or  the  other  limb  on  the  same  side. 
They  may  constitute  the  only  symptoms  of  partial 
tetanus,  and  in  any  case  they  constitute  its  primary 
element.  They  may  be  divided  into  two  individual 
types. 

They  may  consist  of  extremely  painful  convulsive 
jerks,  which  are  characterised  by  clonic  movements. 
These  usually  occur  in  paroxysms,  which,  infrequent  or 
only  of  moderate  frequency  at  first,  become  more  and 
more  frequent  as  the  malady  develops.  In  our  own 
observation,  for  example,  the  clonic  contractions  in  the 
thigh  recurred  three  or  four  times  per  minute  ;  in  the 
case  observed  by  Pozzi  the  whole  of  the  wounded  leg 
was  every  ten  seconds  the  seat  of  painful  contractions 
of  the  most  afflicting  character,  until  finally  the  con- 
vulsive jerks  no  longer  exhibited  any  remission,  so  that 
the  wounded  limb  remained  wholly  contractured,  the 
lower  leg  being  slightly  flexed  upon  the  thigh  and  the 
thigh  upon  the  pelvis. 

In  other  cases  (of  which  examples  are  recorded  in 
an  observation  of  Routier's,  and  one  of  Laval's)  these 
convulsive  jerks  are  not  observed,  but  contractures 
appear  which  are  persistent  from  the  outset,  so  that  the 


792        THE  ABNORMAL  FORMS  OF  TETANUS 

limb,  on  palpation,  feels  like  a  block  of  wood.  As  a  rule 
there  is  an  excessively  painful  contracture  of  an  entire 
limb  ;  in  a  case  of  Routier's  the  thigh  was  flexed  upon 
the  pelvis,  and  the  lower  leg  upon  the  thigh  ;  the  toes 
were  strongly  flexed,  and  all  the  muscles  were  rigid. 
In  Laval's  case  the  contracture,  which  commenced  in 
the  foot,  gradually  gaining  the  lower  leg,  had  by  the 
following  day  invaded  the  whole  limb,  which,  as  a  result 
of  the  generalised  contracture,  was  in  a  position  of  forced 
extension  :  the  foot,  the  lower  leg,  and  thigh  formed  a 
whole,  rigid  as  a  bar  of  iron,  which  seemed  welded  to 
the  pelvis. 

We  see,  then,  that  the  contractures  may  reveal 
themselves,  clinically,  by  clonic  movements  recurring 
in  paroxysms  of  varying  frequency,  or  by  a  generalised 
tonic  contracture,  which  gives  the  limb  a  very  char- 
acteristic appearance.  Contracture  in  extension,  the 
usual  type  of  contractures  of  the  lower  limb,  is  the  rule  ; 
contracture  in  flexion  is  a  rarer  type. 

We  have  mentioned  that  it  is  during  this  period  of 
acme  that  the  traces  of  generalisation  may  make  their 
appearance,  enabling  us  with  certainty  to  establish  a 
diagnosis  of  tetanus.  It  must  not  be  forgotten — and 
we  wish  to  lay  stress  upon  this  point — that  these  signs 
are  ephemeral,  are  not  very  marked,  and  are  sometimes 
absent. 

In  some  cases  the  patient  complains  of  a  pain  situ- 
ated in  front  of  the  ears,  with  difficult  and  painful 
movements  of  deglutition.  This  phenomenon,  which 
in  the  classic  forms  of  tetanus  usually  marks  the  com- 
mencement of  the  period  of  acme,  is  here  of  secondary 
importance,  and  as  a  rule  disappears  within  twenty-four 
or  twenty-eight  hours.  The  pain,  moreover,  is  quite 
moderate. 


MONOFLEGIC  FORM  793 

Stiffness  of  the  back  of  the  neck  is  more  frequent ; 
the  transient  contracture  is  not  very  marked.  The 
forward  flexion  of  the  head  and  neck  is  painful  for  a 
few  days,  at  the  time  when  the  localised  tetanic  con- 
tractures of  the  wounded  limb  reach  their  maximum. 
The  contracture  is  never  accompanied  by  the  retrover- 
sion of  the  head. 

The  muscles  of  the  face  are  in  general  little  affected, 
and  the  risus  sardonicus  is  never  observed. 

The  muscles  of  the  trunk  are  usually  unaffected; 
opisthotonos,  emprosthotonos,  and  pleurothotonos  are 
never  observed. 

Routier,  on  the  other  hand,  has  mentioned,  as  an 
important  symptom  in  localised  tetanus,  a  more  or  less 
marked  contracture  of  the  muscles  of  the  ahdominal  wall. 
We  must  not  attach  to  this  sign  the  importance  attri- 
buted to  it  by  Berard  and  Lumiere,  in  respect  to  the 
gravity  of  the  prognosis.  These  writers  regard  it  as 
the  precursor  of  contracture  of  the  respiratory  muscles 
and  asphyxia  ;  but  in  many  cases  in  which  this 
abdominal  contracture  has  occurred  recovery  has 
followed. 

General  Indications. — General  indications  have  not 
the  same  value  here  ars  in  the  classical  form  of  tetanus. 
For  exampl'e,  the  rise  -X)f  temperature  is  very  irregular. 
Sometimes  it  rises  at  the  outset,  sometimes  only  two  or 
three  days  later,  and  while  it  sometimes  attains  104°  F., 
it  is  more  usual  to  see  the  thermometer  oscillate  between 
100-5°  and  101-5°  F.  However,  the  thermal  curve  is 
usually  ascendant  fibm  the  commencement  of  the 
pains,  remaining  high  until  their  disappearance. 

In  the  usual  form  of  tetanus  the  temperature  is  a 
great  help  to  prognosis  ;  if  the  temperature  is  very  high 
the  case  is  very  serious  ;  if  the  temperature  is  moderate 


794  THE  ABNORMAL  FORMS  OF  TETANUS 

the  tetanus  will  be  a  chronic,  less  serious  form,  from 
which  recovery  is  possible.  In  localised  tetanus  the 
indication  derived  from  an  examination  of  the  tempera- 
ture is  no  longer  of  value.  Thus  in  the  two  fatal  cases 
recorded  by  Routier  the  temperature  never  rose  above 
102-2°  F. 

The  pulse  is  accelerated,  but  remains  regular.  The 
rate  varies,  as  a  rule,  from  100  to  120  pep  minute,  but 
one  never  observes  the  extreme  rapidity,  nor  the  feeble- 
ness, nor  the  irregularities  -which  are  noted  in  the 
normal  forms  of  generalised  tetanus. 

We  may  add,  also,  that  the  urine  diminishes  in 
quantity,  that  retention  of  urine  may  occur,  and  that 
the  face  becomes  covered  with  sweat  at  the  moment  of 
the  convulsive  paroxysms. 

The  facial  aspect  of  the  patient,  on  which  we  insisted 
when  speaking  of  the  period  of  onset,  becomes  still 
more  characteristic.  The  patient  is  extremely  anxious, 
even  during  the  periods-  of  calm,  and, his  face  assumes 
a  curious  expression,  W'hich  strikes  the  observer  at  the 
first  examination.  We  shall  see  that  this  peculiar 
facial  aspect  is  plainly  defined  in  the  attenuated  forms 
ot  the  disease. 

The  pulmonary  disorders  are  not  very  marked,  the 
acceleration  of  the  respiratory  movements  is  slight, 
and,  although  in  the  ordinary  form  of  tetanus  the 
contrary  is  the  case,  the  respiration  never  becomes 
dyspnceic  ;  it  is  never  more  than  slightly  embarrassed. 

Let  us  note  that  the  patient,  as  in  the  generalised 
forms  of  the  tetanic  infection,  always  exhibits  photo- 
phobia and  a  terror  of  noise  and  movement,  which  are 
due  to  the  hypersensitiveness  of  the  organs  of  the  senses. 
Lastly,  the  intelligence,  even  in  the  midst  of  the  painful 
paroxysms,  always  remains  unaffected. 


MONOPLEGIC  FORM  795 

Examination  of  Reflexes. — Examination  of  the  re- 
flexes' in  local  tetanus  reveals  a  constant  exaggeration 
of  the  osseous  and  tendinous  reflexes,  with  ankle  and 
patellar  clonus.  Percussion  of  the  zygoma  causes,  in 
certain  patients,  a  sudden  extensor  movement  of  the 
head.  The  masseteric  reflex  may  be  exaggerated  ;  it 
was  so  in  the  case  observed  by  the  present  writer. 

This  exaltation  of  the  osseous  and  tendinous  reflexes 
is  associated  with  a  hyper-excitability  of  the  muscles 
and  nerves  to  galvanism  and  faradaism.  This  sign  is 
observed  also  in  the  attenuated  forms  of  tetanus 
described  by  Claude  and  Lhermitte.  It  must  be  re- 
membered, however,  that  the  exaggeration  of  the  re- 
flexes may  be  accompanied,  as  in  the  case  observed  by 
the  present  writers,  with  hypo-excitability  of  the  nerves 
to  electric  stimulation. 

In  localised  tetanus,  as  in  the  generalised  form,  the 
blood  exhibits  no  special  reaction.  The  hsematological 
formula  depends  upon  the  condition  of  the  initial 
wound  and  the  presence  or  absence  of  septicaemia  or 
anaemia. 

It  is  the  same  with  the  cerebro-spinal  fluid,  which 
reveals  no  appreciable  modification ;  there  is  no 
cellular  reaction,  no  increase  of  albumin.  The  liquid 
yielded  by  a  lumbar  puncture  is  sterile  and  non- toxic. 

To  sum  up.  The  period  of  acme  in  local  tetanus, 
whether  early  or  postponed,  is  characterised  by  : 

1.  Contractures  confined  to  one  limb,  with  more  or 
less  frequent  spasmodic  paroxysms,  without  lasting 
phenomena  of  generalisation. 

2.  No  very  noticeable  general  signs  ;  the  tempera- 
ture is  not  high  ;  the  pulse  is  regular,  not  exceeding 
120,  and  the  respiration  is  but  slightly  embarrassed. 

3.  An  exaggeration  of  the  reflexes. 


796       THE  ABNORMAL  FOBMS  OF  TETANUS 

4.  A  chronic  development  and  a  tendency  toward 
recovery  in  the  majority  of  cases,  as  we  shall  presently 
see  when  considering  the  progress  and  the^  prognosis  of 
the  various  forms  of  local  tetanus  of  the  limbs. 


Diagnosis 

Positive  Diagnosis. — ^While  the  diagnosis  of  general- 
ised tetanus  presents  no  difficulty ;  while  trismus, 
opisthotonos,  and  the  clonic  contractions  of  the  whole 
body  form  a  symptom  complex  easily  recognised, 
matters  are  otherwise  in  the  partial  forms  of  tetanus, 
at  all  events  in  the  beginning.  We  must  suspect  a 
localisation  of  tetanus  when,  the  wound  being  still 
uncicatriscd,  or  well  on  the  way  to  cicatrisation,  the 
wounded  limb  sooner  or  later  becomes  the  seat  of  pains 
or  cramps  which  must  be  regarded  as  the  first  mani- 
festations of  contractures.  Above  all,  the  diagnosis 
must  incline  toward  the  tetanic  infection  when  the 
pains  and  contractures  are  influenced,  awakened,  and 
intensified  by  sounds  or  movements  or  lights.  In  such 
a  case  one  may  affirm  with  practical  certainty,  even  if 
the  patient  received  a  preventive  injection  of  10  c.c.  of 
antitetanic  serum  within  a  few  hours  of  being  wounded, 
that  he  is  suffering  from  tetanus. 

Nevertheless,  it  must  not  be  supposed  tliat  hesitation 
is  impossible  ;  on  the  appearance  of  the  first  con- 
tractures it  is  often  difficult  to  form  a  decision,  for  which 
reason  we  would  gladly  appeal  to  the  laboratory  for 
the  certain  information  which  clinical  science  is  unable 
to  yield.  Unfortunately,  as.  we  shall  sec,  there  is  no 
sero-diagnosis  of  tetanus  by  the  agglutination  test 
(Courmont).  Proceeding  from  this  fact,  certain 
writers   have   recommended   a    direct   search   for   the 


MONOPLEGIC  FORM  797 

presence  of  Nicola ier's  bacillus  in  the  wound.  But  the 
bacteriological  examination  of  the  secretions  of  a 
wound  often  yielding  results  of  too  uncertain  a  nature, 
many  clinicians  are  of  opinion  that  experiments  upon 
animals  are  greatly  superior  to  morphological  examina- 
tion, or  culture,  for  the  purpose  of  determining  whether 
the  tetanic  bacillus  does  or  does  not  exist  in  the  wound. 
Jacobsthal  even  writes  that  this  is  the  ideal  method, 
although  such  experiments  occasionally  fail.  This 
failure  may  be  attributed  to  the  degeneration  of 
anaerobic  germs  resulting  from  a  mixed  infection. 

In  the  early  stage  of  tetanus,  accordingly,  the 
laboratory  is  of  no  value  as  an  auxiliary  to  clinical 
science,  and  it  is  greatly  to  be  regretted,  from  the 
therapeutic  point  of  view,  that  the  presence  of  the  toxin 
in  the  patient's  blood  cannot  be  determined  before  the 
first  symptoms  make  their  appearance. 

M'Clintock  and  Hutchinson,  however,  were  able  to 
prove  the  presence  of  the  toxin  in  the  blood  of  sheep 
which  had  been  infected  with  tetanus  four  days  before 
the  appearance  of  the  clinical  indications. 

Di^rential  Diagnosis.- — Under  these  conditions  it 
will  be  understood  that  right  at  the  outset,  particularly 
in  the  late-appearing  localised  forms,  a  certain  number 
of  affections  may  give  rise  to  confusion,  more  or  less 
faithfully  simulating  partial  tetanus. 

1.  A  spasmodic  monoplegia  of  cerebral  or  medullary 
origin  may  be  characterised  by  cerebral  disorders 
(ictus,  dysarthria,  vertigo,  headache,  sphincterial 
trouble,  and  modifications  of  the  tendinous  reflexes). 
There  is  no  trismus,  and  no  painful  and  spasmodic  in- 
tensification of  the  phenomena,  and  the  development  is 
not  rapid.  It  is  easy  to  differentiate  tetanic  paroxysms 
from  the  paroxysms  of  Jacksonian  epilepsy,  and  from 


798    THE  ABNORMAL  FORMS  OF  TETANUS 

the   syndrome   described   by  Kojejnikov,    under   the 
name  of  continuous  partial  epilepsy. 

2.  The  same  is  true  of  incomplete  hemiplegia  with  pre- 
dominance of  the  signs  in  one  limb. 

3.  The  syndrome  of  excitation  or  irritation  of  the 
motor  nerves  and  the  mixed  nerves,  which  may  reveal 
itself,  apart  from  the  pains,  by  the  exaggeration  of  the 
tendinous  reflexes  and  by  contracture,  is  more  difficult 
to  distinguish  from  partial  tetanus.  The  examples 
recorded  by  Le  Fort,  Dupre,  Schoeffer,  and  Le  Fur  are 
particularly  instructive  in  this  connection. 

Rene  Le  Fort,  in  a  work  entitled  Pseudo-Tetanic 
Symptoms  in  Wounded  Men  suffering  from  Lesions  of  the 
Nerves  complicated  by  the  Presence  of  Foreign  Bodies, 
refers  to  the  clinical  history  of  three  patients,  who, 
having  been  previously  given  a  preventive  injection  of 
antitetanic  serum,  exhibited  painful  and  spasmodic 
symptoms  in  the  wounded  limb,  with  contracture  in 
hyper-extension  in  one  case,  and  in  hyperflexion  in  the 
other  two  cases.  These  symptoms  disappeared  after 
the  removal  of  foreign  bodies  which  were  in  contact 
with  the  nerves.  The  hypothesis  of  partial  tetanus 
cannot  be  rejected  with  certainty,  at  all  events  in  one 
of  these  cases,  for  the  contracture  invaded  the  un- 
wounded  limb,  and  the  symptoms  at  one  time  assumed 
a  serious  character  which  was  not  consistent  with  a 
simple  nervous  lesion. 

The  observation  published  by  Dupre,  Schoeffer,  and 
Le  Fur  dealt  with  a  patient  wounded  on  the  20th 
September  1914,  who  had  not  received  a  preventive 
injection,  and  who  was  attacked,  a  week  after  the 
traumatism,  by  a  serious  and  acute  form  of  tetanus, 
which  terminated  in  recovery.  The  right  leg  remained 
flexed,  and  an  operation  was  performed  on  the  sciatic 


MONOPLEGIC  FORM  799 

nerve  on  the  7th  January  1915.     In  June  the  limb  still 
presented  tetanic  spasms,  occurring,  in  particular,  on 
walking,  and  remaining  refractory  to   all  treatment. 
Dupre,  Schceffer,  and  Le  Fur  discuss  the  possibility  of 
a  psycho-neurosis,  or  of  a  chronic  tetanus.     While  the 
hypothesis  of  a  psycho-neurosis  is  hardly  probable,  that 
of  tetanus   is  more  so  ;    but  we  may  ask  ourselves 
whether  the  lesion  of  the  sciatic  nerve  was  not  the 
origin  of  the  tetanic  spasms.     However,  the  existence 
of  a  previous  attack  of  acute  tetanus,  and  the  character 
of  the  spasms,  which  were  not  localised  in  the  wounded 
limb,   but  were  generalised,   sometimes  invading  the 
masseters,  argue  in  favour  of  chronic  tetanus.     It  may 
also  be  the  case  that  the  lesion  of  the  sciatic  nerve 
favoured  the  persistence  of  the  spasms  after  the  develop- 
ment  of  acute   tetanus,    and   determined   their   pre- 
dominance in  the  wounded  limb.     This  is  a  CQmplex 
problem,    and    one   difficult   of   solution.     A   nervous 
lesion  may  not  only  simulate  a  local  form  of  tetanus, 
but  may  also  favour  its  development.     It  will  be  under- 
stood, in  short,  that  a  slight  wound  of  a  nerve  might 
localise  the  action  of  the  tetanic  toxin  along  its  course, 
but  we  may  also  conceive  that  a  nervous  lesion  anterior 
to  tetanus  might  favour  the  appearance  of  the  latter. 
The   observation   published   by   Phelip   and   Policard 
shows  this  determining  influence  ;   it  deals  with  a  sub- 
acute and  benign  case  of  tetanus,  which,  in  spite  of  two 
preventive  injections,  developed  seventeen  days  after 
an  excoriation  of  the  hand  ;   the  wounded  limb,  which 
was  the  initial  seat  of  the  tetanic  signs,  had  several 
years    previously    been    attacked    by    a    traumatic 
neuritis  of  the  median  nerve. 

4.  The  contractures  or  pseudo-contractures  follow- 
ing upon  lesions  of  the  bones,  the  joints,  the  tendons,  or 


800    TEE  ABNORMAL  FORMS  OF  TETANUS 

the  muscles,  are  differentiated  by  their  stabihty  and 
the  fixed  position  imposed  upon  the  limb,  while  a 
careful  examination  of  the  region  involved  will  always 
enable  the  physician  quickly  to  discover  the  cause  of 
the  contractures. 

5.  In  tetany  we  find  contractures  of  the  muscles  of 
the  extremities,  which  may  extend  to  the  limbs, 
occurring  in  paroxysms  of  very  variable  duration.  The 
onset  may  occur  unheralded,  or  may  be  preceded  by 
prodromal  symptoms  consisting  of  disorders  of  sensi- 
bility, formication,  numbness  of  the  hands  and  fingers, 
and  muscular  stiffness,  and  of  general  disorders : 
general  malaise,  cephalalgia,  and  fever.  The  con- 
tracture is  the  capital  sign  of  tetany. 

The  contractures  involve,  simultaneously  or  alter- 
nately, the  upper  and  lower  extremities  ;  they  are 
sometimes  confined  to  one  pair  of  extremities  only, 
usually  the  upper.  The  contractured  muscles  are 
hard,  and  raise  the  skin  like  tightly  stretched  cords. 
It  is  usually  fairly  easy  to  reduce  the  contracture 
and  restore  the  members  to  their  normal  attitude, 
but  the  deformation  reappears  directly  they  are 
released. 

The  pains,  which  are  spontaneous  and  moderate, 
occur  in  the  affected  muscles,  and  along  the  nerves  of 
the  limb,  sometimes  irradiating  over  the  trunk. 

These  contractures,  as  we  have  remarked,  occur  in 
paroxysms  lasting  five,  ten,  or  fifteen  minutes,  occasion- 
ally one,  two,  or  three  hours.  The  reappearance  of  the 
sensation  of  formication  announces  the  termination  of 
the  paroxysms.  After  a  period  of  repose  the  fit  recurs, 
and  the  series  of  fits  constitutes  the  attack,  which  may 
last  for  some  days,  or  may  persist  even  for  one,  two,  or 
three  months. 


MONOPLEGIC  FORM  801 

Three  forms  of  tetany  may  be  distinguished  :  a 
benign  form,  a  form  of  medium  severity,  and  a  grave 
form.  It  is  more  particularly  the  benign  form,  in 
which  the  contracture  may  involve  a  single  member, 
which  may  be  confounded  with  localised  tetanus  on  a 
superficial  examination. 

Examination  of  the  mechanical  and  electrical  excit- 
ability of  the  muscles  reveals  the  existence  of  several 
signs  which  are  almost  pathognomic.  These  are 
Trousseau's  sign,  Weiss's  sign,  and  Chvostek's  sign,  or 
the  sign  of  the  facial  nerve. 

Trousseau's  Sign. — At  any  time  before  the  termina- 
tion of  the  malady  one  may  cause  the  fits  to  recur  at 
will,  even  though  none  have  occurred  for  one,  two,  or 
three  days,  or  more.  This  is  effected,  says  Trousseau, 
by  exerting  compression  on  the  affected  member,  either 
upon  the  course  of  the  principal  nerves,  or  upon  the 
blood-vessels.  Thus,  by  exerting  pressure  on  the 
median  nerve  of  the  arm,  or  the  brachial  plexus  above 
the  clavicle,  the  contracture  occurs  immediately.  In 
the  lower  limb,  if  the  femoral  artery  or  the  sciatic  nerve 
be  compressed,  or  a  ligature  applied  to  the  thigh,  the 
muscular  spasms  recur  in  the  lower  extremities,  although 
less  readily. 

Weiss's  Sign. — The  percussion  of  the  temporo-facial 
branch  at  the  outer  angle  of  the  orbit  may  provoke  a 
contraction  of  the  orbital,  frontal,  and  superciliary 
muscles. 

Chvostek's  Sign,  or  the  sign  of  the  facial  nerve,  reveals 
neuro-muscular  hyper-excitability  of  the  face.  Slight 
percussion  of  the  facial  nerve  in  the  cheek  causes  a 


802      THE  ABNORMAL  FORMS  OF  TETANUS      ' 

sudden  contraction,  "  like  a  flash  of  lightning,"  of  the 
muscles  innervated  by  the  facial  nerve. 

Another  sign  has  been  described,  which  is  obtained 
by  raising  and  forcibly  flexing  the  lower  limbs,  main- 
tained in  extension,  upon  the  trunk  ;  a  prompt  con- 
traction of  the  muscles  of  the  legs  is  produced,  placing 
the  foot  in  forced  inversion. 

In   tetany  we   find   also   hyper- excitability   of  the 
muscles  and  nerves  to  galvanism.     The  reflexes  are 
maintained,  and  often  exalted,  and  one  occasionally 
notes  vasomotor  and  trophic  disorders.     In  addition 
to    these    signs   there    is,    lastly,    a    special    etiology 
which   determines   the   diagnosis.      It    is   at    present 
supposed   that  tetany   is  caused  by  an   intoxication 
which   acts   upon   certain   elements   of   the   nervous 
system,  and  is  itself  caused  by  digestive  troubles  or 
by  a  special  glandular  insufficiency  (the  parathyroid 
theory).      Recent   investigations,    indeed,    permit    us 
to   suspect,   in   cases  of  tetany  of  gastric   origin,   a 
parathyroidal   insufficiency,   and    the   toxic   disorders 
resulting  therefrom.    We  know,  since  the  publication 
of  the  results  of  Gley's  investigations,  that  ablation 
of   the    parathyroids    sometimes    gives    rise    in   man 
and  in   certain   animals   to   grave  tetanic  symptoms 
which    are    often    fatal    (the     tetany    of    operative 
myxoedema). 

6.  Acute  strychnine  'poisoning  might  possibly  cause 
confusion.  It  greatly  resembles  tetanus,  especially  at 
the  outset,  for  at  this  period  the  contractures  caused 
by  strychnine  affect  only  the  muscles  of  the  lower  limbs, 
becoming  generalised  subsequently. 

The  intoxication  is  preceded  by  yawning  and  retinal 
hyperaesthesia.  The  pupils  are  dilated,  and  objects 
appear  green  to  the  eye.     There  is  often  delirium  from 


MONOPLEGIC  FORM  803 

the  outset,  while  in  tetanus  the  inteUigence  is  usually 
unaffected. 

7.  Hysterical  contractures  may  also  simulate  tetanic 
contractures,  the  more  so  as  they  may  be  partial, 
occupying  a  group  of  muscles,  a  segment  of  a  limb,  or  a 
whole  limb. 

The  contracture  appears  after  a  convulsive  attack, 
or  more  rarely  without  appreciable  cause,  when  it  may 
be  the  first  manifestation  of  neurosis  (Babinski). 

Its  onset  is  sudden  and  rapid,  and  it  attains  its 
maximum  intensity  at  once,  or  very  quickly.  The 
rigidity  may  be  extreme,  and  very  difficult  to  over- 
come, causing  excessive  deformation.  Hysterical 
contractures  are  usually  accompanied  by  objective  dis- 
orders of  the  sensibility  :  anaesthesia,  or  hypergesthesia, 
whose  topography  is  regional,  often  being  confined  to 
the  territory  occupied  by  the  contracture. 

Its  duration  is  extremely  variable.  It  may  persist 
for  a  few  days  or  a  few  months.  It  may  disappear  as  it 
came — that  is,  suddenly,  after  an  attack,  or  as  a  result 
of  suggestive  treatment. 

It  may  also  disappear  slowly,  little  by  little.  It 
ceases  temporarily,  and  sometimes  finally,  under 
chloroform.  Its  differential  diagnosis  is  readily  estab- 
lished by  the  fact  that  the  reflexes  are  not  modified 
(Babinski) ;  there  are  no  spasmodic  and  painful 
intensifications,  and  there  is  no  trismus. 

Everything  being  considered,  the  establishment  oi 
the  diagnosis  of  localised  tetanus  is,  at  the  outset,  a  very 
delicate  matter,  but  the  affections  which  may  cause 
confusion,  in  particular  tetany,  the  syndrome  of 
excitation  of  the  motor  nerves,  hysterical  contractures, 
and  acute  strychnine  poisoning,  possess  a  sufficiency  of 
peculiar  and  characteristic  signs  to  make  it  possible, 


804        THE  ABNORMAL  FORMS  OF  TETANUS 

in  the  majority  of  cases,  to  diagnose  them  promptly. 
Moreover,  the  evolution  of  the  disease  furnishes  data 
which  assist  us  to  recognise  the  nature  of  the  con- 
tractures, and  to  show  that  we  have  to  deal  with  a 
localised  tetanic  infection. 


CHAPTER  IV 


PARAPLEGIC   FORM 


This  form  of  the  tetanic  infection,  localising  itself  in 
two  symmetrical  members,  was  particularly  considered 
by  Demontmerot  in  his  inaugural  thesis  in  1904.  But 
certain  of  the  cases  recorded  by  this  writer  do  not  come 
under  the  heading  of  partial  tetanus,  for  after  a  first 
ephemeral  localisation  in  the  two  lower  limbs  trismus  and 
stiffness  of  the  neck  and  the  trunk  set  in.  These  were 
therefore  cases  of  classic  tetanus  with  paraplegic  onset. 

It  must  be  remembered,  also,  that  hybrid  forms  may 
occur,  intermediate  between  the  monoplegic  and  para- 
plegic types.  The  one  type  shows  itself  for  a  few  days 
only,  disappearing  and  leaving  no  traces.  Pozzi's 
observation  is  the  first  published  record  of  this  clinical 
variety.  It  describes  a  localised  tetanus  with  the 
monoplegic  type  predominant,  the  opposite  lower  limb 
being  affected  for  a  few  days,  during  which  period  it 
assumed  the  paraplegic  type. 

However  this  may  be,  the  paraplegic  form  of  local 
tetanus  may  assume  two  clinical  aspects,  accordingly 
as  the  localisation  is  in  the  upper  or  the  lower  limbs. 
These  are  :  (1)  the  superior  paraplegic  type  ;  (2)  the 
inferior  paraplegic  type. 

Symptomatology 

The  signs  of  the  onset,  whichever  form  of  the  malady 
is  in  question,  are  identical  with  those  observed   in 

805 


806       TBE  ABNORMAL  FORMS  OF  TETANUS 

monoplegic  tetanus.  In  this  connection  we  refer  the 
reader  to  the  local  and  general  modifications  mentioned 
in  the  preceding  chapter. 

It  must  be  remembered  that  in  this  variety  it  is  princi- 
pally the  late-appearing  form  which  is  encountered ; 
the  period  of  incubation  is  almost  invariably  long  : 
a  fortnight,  three  weeks,  or  more. 

(a)  Inferior  Paraplegic  Type. — ^The  inferior  para- 
plegic type  is  by  far  the  most  frequent.  The  lower 
limbs  are  the  seat  of  convulsive  jerks  of  incredible 
frequency,  still  further  exaggerated  by  the  slightest 
emotion,  the  slightest  agitation,  the  least  shock  or 
vibration. 

In  the  period  of  acme  paroxysms  with  remissions  are 
observed.  The  attitude  of  the  members  has  been  well 
described  by  Demontmerot.  The  limbs,  he  states,  are 
in  forced  extension,  the  foot  strongly  depressed,  the 
instep  salient,  the  toes  usually  turned  under.  Alto- 
gether, the  foot  reproduces  with  a  fair  degree  of  exact- 
ness the  attitude  of  talipes  equinus. 

The  muscles  of  the  calf  are  stretched  to  the  maximum, 
giving  on  palpation  the  sensation  of  an  extremely  hard, 
solid  cord.  The  lower  leg  itself  is  extended  to  the 
maximum,  the  patella  firmly  immobilised,  while  the 
thigh  is  in  extension  upon  the  pelvis. 

In  most  cases  the  contracture  invades,  at  least,  the 
lower  abdominal  muscles,  so  that  the  belly  is  enclosed 
by  a  hard,  unyielding  wall.  Despite  the  importance 
which  Berard  and  Lumi^re  are  inclined  to  attribute 
to  it,  we  have  seen  what  prognostic  value  should 
be  attached  to  this  sign  in  connection  with  the  mono- 
plegic form.  No  amount  of  effort  will  restore  the 
movements  of  flexion  to  the  various  segments  of  the 
limb,  but  the  entire  lower  limb,  fixed   in  extension, 


PAEAPLEGIC  FORM  807 

may  readily  be  lifted  in  one  piece,  as  it  were,  by  the 
toes. 

This  muscular  rigidity  becomes  accentuated  very 
rapidly,  so  that,  apart  from  any  convulsive  paroxysm, 
and  after  the  paroxysms  themselves  have  disappeared, 
the  lower  limbs  are  absolutely  immobile. 

When  this  form  is  unmixed,  leaving  the  patient  the 
free  use  of  the  upper  limbs,  the  superior  vertebral  arti- 
culations, and  the  muscles  of  the  face,  it  gives  the  patient 
an  appearance  which  is  completely  characteristic. 

It  seems  as  though  the  lower  half  of  the  body  has 
suddenly  been  transformed  into  a  lifeless  mass,  so  that 
one  has  before  one's  eyes  one  of  those  fantastic  mytho- 
logical beings  created  by  the  Oriental  imagination,  the 
upper  half  of  whom,  being  mobile  and  alive,  offers  a 
striking  contrast  to  the  lower  half,  which  is  immobile, 
and,  as  it  were,  petrified. 

(b)  Superior  Paraplegic  Form. — In  the  superior  para- 
plegic form,  of  which  only  one  case  is  known  (Demont- 
merot),  the  upper  arms,  forearms,  wrists,  and  hands  were 
in  forced  flexion.  The  phalanges  were  folded  down 
upon  the  palm  of  the  hand,  the  thumb  inserted  inside 
the  phalange  of  the  forefinger,  and  strongly  compressed 
by  it  ;  the  distorted  hand  was  drawn  violently  down 
toward  the  forearm  by  the  flexion  of  the  wrist ;  the 
forearm,  which  was  stiff,  with  the  integuments  raised 
by  the  tendinous  cord  of  the  flexor  muscles,  made  a  very 
acute  angle  with  the  upper  arm  ;  lastly,  the  upper  arm 
was  closely  pressed  against  the  thorax. 

This  position,  carried  to  its  extreme  during  paroxysms, 
presently  persisted  apart  from  these  and,  as  in  the  in- 
ferior form,  prohibited  any  use  of  the  limbs. 

In  both  types  the  development  of  paroxysms  causes 
violent  pain  in  the  members  affected. 


808       THE  ABNORMAL  FORMS  OF  TETANUS 

The  reflexes  remain  normal ;  Demontmerot  observed 
neither  clonus  nor  exaggeration  of  the  reflexes.  The 
sensibility  is  normal. 

Lastly,  the  general  signs  are  not  marked ;  there  is 
only  a  slight  elevation  of  temperature,  the  ther- 
mometer varying  between  98*6°  and  100-4°  F.  :  but 
this  slight  temperature  quickly  disappears  once  the 
paroxysm  is  terminated.  This  comparative  athermia 
constitutes,  as  we  shall  see,  another  sign  of  a  benign 
development. 

The  general  condition  remains  good  ;  we  need  only 
mention  the  abundant  sweats,  and  the  absence,  upon 
examination,  of  any  special  organic  disorders. 

Such — expressed  in  outline — is  the  usual  condition 
of  the  patient  in  the  paraplegic  form  of  localised  tetanus. 
Very  rarely,  however,  is  the  clinical  picture  unmixed. 
We  have  already  mentioned  the  unexpected  appearance 
of  generalised  contractures,  and  in  this  connection  we 
shall  ask  the  reader  to  remember  that  there  are,  in 
addition  to  the  true  localised  form  of  tetanus,  two  forms 
of  generalised  tetanus  which  writers  on  the  subject  have 
confused  with  the  partial  forms. 

Sometimes  the  generalised  contractures  happen  to 
mask,  for  a  time,  the  initial  paraplegic  localisation  ; 
this  is  what  we  have  described  as  "  the  classic  form  of 
tetanus  with  paraplegic  onset." 

Sometimes,  on  the  contrary,  tetanus  exhibits  an 
absolutely  normal  onset,  with  trismus,  opisthotonos, 
and  fever,  and  only  subsequently  does  the  affection 
more  especially  assume  an  increasingly  definite  para- 
plegic form.  In  addition  to  the  classic  tetanus  para- 
plegic at  the  first  onset,  we  must,  therefore,  recognise 
a  generalised  tetanus  with  paraplegic  development,  or 
a  secondary  paraplegic  form. 


PARAPLEGIC  FORM  809 

Considering  the  evolution  of  these  paraplegic  partial 
forms,  we  shall  at  onoe  perceive  that  it  resembles  that 
of  the  monoplegic  form — that  is,  it  is  very  slow — and  we 
may  distinguish  four  periods  of  development.  Lastly, 
we  may  remark  that  the  prognosis  is  favourable. 


Diagnosis 

In  a  late-appearing  form  of  tetanus  particularly — • 
which  means  in  the  majority  of  cases — the  total  absence 
of  a  clinical  history  may  for  some  days  hold  the  diag- 
nosis in  abeyance. 

It  should  always  be  an  easy  matter,  after  an 
attentive  and  thorough  examination  of  the  nervous 
system,  to  eliminate  the  paraplegias  resulting  from 
peripheral  and  radicular,  or  medullary,  or  cerebral 
lesions. 

Three  affections  in  particular,  by  their  very  similar 
initial  symptomatology,  simulate  localised  paraplegic 
tetanus  with  some  exactness.  These  are,  on  the  one 
hand,  tetany  and  hysterical  paraplegia  ;  on  the  other 
hand,  cerebro-spinal  meningitis. 

We  shall  not  insist  upon  the  differential  diagnosis  of 
tetany  and  hysteria,  which  we  mentioned  when  speaking 
of  the  monoplegic  form. 

This  leaves  us  to  consider  cerebro-spinal  meningitis, 
whose  diagnosis  is  comparatively  easy.  It  suffices  to 
remember  that  the  spasms  are  quickly  replaced  by 
paralysis,  that  there  is  intense  headache,  with  photo- 
phobia, vomiting,  and  spinal  pains  upon  pressure. 
The  laboratory,  moreover,  provides  us  with  exact 
information  by  the  chemical  and  cytological  examina- 
tion of  the  cerebro-spinal  fluid. 

In  cerebro-spinal  meningitis  lumbar  puncture,  which 


810       THE  ABNORMAL  FORMS  OF  TETANUS 

should  always  be  practised  directly  there  is  the  slightest 
suspicion  of  the  possibility  of  a  meningeal  reaction,. 
yields  a  turbid  fluid,  sometimes  obviously  purulent, 
with  an  increase  of  albumin,  polynuclear  reaction,  and 
the  presence  of  meningiococci. 


CHAPTER  V 

LOCALISED    TETANUS    OF    THE   ABDOMINO- 
THORACIC   TYPE 

This  variety  of  partial  tetanic  infection  is  quite  ex- 
ceptional. In  the  whole  literature  of  medicine  there  is 
only  one  record  of  such  a  case  of  late  and  local  tetanus. 
It  developed  one  hundred  and  thirty  days  after  the 
wound,  and  after  the  preventive  injection  of  10  c.c.  of 
anti tetanic  serum. 

The  rarity  of  an  exclusive  and  late-appearing  tetanic 
localisation  in  the  abdomino-thoracic  muscles  is  such 
that  we  have  decided  to  reproduce  the  unique  and 
highly  interesting  observation  published  by  P.  L.  Marie. 

Observation  fP.  L.  Marie) 

C ,  aged  thirty-one  years,  who  had  already,  in  January, 

1915,  received  a  traversing  wound  in  the  left  arm,  after  which 
he  was  given  ]0  c.c.  of  antitetanic  serum,  was  again  wounded, 
on  the  10th  July  following,  by  shell-splinters,  which  caused 
numerous  wounds  of  the  face,  the  scalp,  the  upper  part  of  the 
thorax,  the  left  arm,  and  the  left  lower  leg.  Nearly  all  were 
superficial  and  of  very  small  dimensions.  Three  deserve 
special  mention :  the  first  involved  the  left  eye,  of  which  the 
cornea  was  perforated  and  the  lower  Ud  lacerated ;  of  the 
other  two,  which  were  fairly  extensive  and  penetrating,  one 
was  situated  in  the  left  forearm  and  one  on  the  inner  face  of 
the  left  thigh.  Two  days  after  the  wound  10  c.c.  of  anti- 
tetanic  serum  were  injected,  without  anaphylactic  symptoms. 
On  the  13th  July,  at  the  Centre  ophtalmologique  in  Rouen, 
enucleation  of  the  eye  was  performed,  followed,  four  days  later, 

811 


812      THE  ABNORMAL  FORMS  OF  TETANUS 

by  the  incision  of  a  phlegmon  in  the  forearm,  with  extrac- 
tion of  a  spHnter.  Finally  several  operations  were  performed 
with  a  view  to  blepharoplasty.  During  this  time  all  the 
wounds  had  healed  quickly,  excepting  that  on  the  thigh, 
which  left  a  small  fistula  which  discharged  very  slightly. 

About  the  10th  November  the  patient,  until  then  in  per- 
fect health,  began  to  complain  of  intermittent  shooting  pains 
in  the  abdomen,  thorax,  and  loins,  these  pains  being  presently 
accompanied  by  persistent  muscular  contracture  in  the 
abdomino-lumbar  region. 

Suspecting  an  attenuated  form  of  tetanus,  chloral  was 
prescribed  [S  grammes  per  diem).  However,  far  from  im- 
proving, the  condition  became  aggravated.  From  the  20th 
November  sudden  jerks  occurred,  spreading  from  the  waist 
down  to  the  feet,  compared  by  the  patient  to  electric  shocks, 
occurring  in  paroxysms,  which  left  the  upper  limbs  unaffected. 
Finally,  during  the  night  of  the  3rd  December,  disquieting 
respiratory  disorders  appeared  :  frequent  respiratory  pauses 
occurred,  sometimes  attaining  a  duration  of  fifteen  seconds, 
followed  by  slight  polypnoeas.  On  the  6th  December  the 
patient  exhibited  an  intense  contracture  of  the  lower  portion 
of  the  trunk  ;  the  abdominal  wall,  slightly  retracted,  was  in- 
compressible, and  presented  the  stony  hardness  so  character- 
istic of  tetanus.  This  contracture  was  permanent ;  it  was  no 
longer  accompanied  by  pain,  and  was  of  constant  intensity. 

The  period  of  paroxysms  of  painful  contracture  was 
replaced  by  analgesic  muscular  rigidity.  The  dorso-lumbar 
muscles  were  also  contractured,  causing  a  marked  exaggera- 
tion of  the  lumbar  curve.  The  patient  was  able  to  sit  down 
only  with  difficulty,  by  gripping  the  edge  of  the  bed  with 
his  hands ;  and  the  pain  quickly  forced  him  to  lie  down 
again.  When  told  to  pick  an  object  from  the  floor,  he  was 
able  to  do  so  only  with  great  difficulty,  by  flexing  the  knees 
to  the  maximum,  the  trunk  retaining  its  stiffness.  There 
was  no  other  contracture,  excepting  a  bare  trace  of  trismus, 
the  incisors  being  still  capable  of  a  division  of  1'2  inches. 
The  patient  complained  of  a  slight  stiffness  when  he  tried 
to  open  his  mouth  widely,  but  he  was  able  to  eat,  drink, 
and  speak  without  difficulty.  The  back  of  the  neck  and 
the  uj)per  and  lower  limbs  were  perfectly  supple ;  there 
was  no  Kernig's  sign,  but  the  walk  was  embarrassed,  the 
patient  complaining  that  he  could  not  throw  his  legs  forward. 


THE   ABDOMINO— THORACIC    TYPE        813 

The  tendinous  reflexes,  normal  in  the  upper  limbs,  were 
strong  in  the  lower  limbs,  but  notably  more  exaggerated  on  the 
left ;  there  was  no  ankle  or  patellar  clonus.  The  cutaneous  re- 
flexes were  also  stronger  on  the  left,  particularly  that  of  the 
tensor  fasciae  lata.  On  the  inner  face  of  the  left  thigh,  by 
the  upper  edge  of  the  femoral  condyle,  was  the  orifice  of  the 
little  fistula  already  mentioned,  which  had  dried  up  about 
a  fortnight  previously,  and  was  covered  with  crusts.  There 
were  no  disorders  of  the  sphincters ;  and  the  respiratory 
symptoms  had  not  recurred.  The  general  condition  was 
unaffected ;  there  was  neither  fever  nor  emaciation.  It 
should  be  noted,  however,  that  there  was  a  slight  acceleration 
of  the  pulse  (92),  and  an  obvious  exaggeration  of  the  secre- 
tion of  sweat ;  the  whole  body  was  moist,  and  the  face 
was  covered  with  a  veritable  dew. 

The  patient  was  given  40  c.c.  of  antitetanic  serum  by 
subcutaneous  injection,  without  any  subsequent  reaction, 
and  4  grammes  of  chloral,  and,  five  days  later,  a  further  30 
c.c,  of  serum. 

For  ten  days  the  condition  of  the  patient  remained  station- 
ary. The  exaggeration  of  the  lumbar  curve  diminished 
slightly,  but  the  abdomen  was  still  as  hard  as  before.  There 
were  no  spasmodic  paroxysms,  no  respiratory  troubles.  The 
reflexes  were  still  greatly  exaggerated  in  the  left  leg.  The 
temperature  remained  normal,  the  pulse  was  about  80,  and 
there  was  no  constipation. 

The  fistula  intermittently  discharged  a  few  drops  of 
serous  fluid. 

Thinking  that  a  foreign  body  was  helping  to  maintain 
the  suppuration,  and  that  it  had  perhaps  played  some  part 
in  the  development  of  the  tetanus,  and  was  an  obstacle  to 
its  cure,  M.  Marie  had  the  region  of  the  knee  radiographed. 
In.  this  way  a  small  shell-splinter  was  discovered  on  the 
inner  face  of  the  articulation,  2^  inches  below  the  orifice 
of  the  fistula. 

On  the  27th  December  a  third  injection  of  serum  was 
given  (40  c.c.)  in  order  to  guard  against  the  eventual  danger 
of  a  mobilisation  of  germs  when  the  operation  was  performed, 
and  on  the  following  day  the  projectile  was  removed  under 
a  local  anaesthetic.  It  was  enclosed  in  a  small  cavity  with 
thick  fibrous  walls,  covered  with  a  small  quantity  of  pus 
which    contained,   in    the    midst   of  numerous    polynuclear 


814       THE  ABNORMAL  FORMS  OF  TETANUS 

leucocytes  which  were  more  or  less  cytolised^  bacillary  ele- 
ments of  various  dimensions.  The  immediate  culture  of  the 
germs  covering  the  splinter  in  glucose  agar  (stab  cultures) 
resulted  in  the  development  of  a  multitude  of  microbic 
colonies.  In  twenty-two  hours  the  medium  broke  up,  with- 
out giving  off  any  odour.  An  examination  conducted  by  Dr 
Ch.  Aubertin  revealed  large  bacilli  with  square  ends,  Gram- 
positive,  having  all  the  characteristics  of  B.  perfringens ; 
long  slender  bacilli.  Gram-negative  ;  a  few  curved  bacilli, 
like  the  septic  vibrio  ;  and  lastly,  some  diplococci,  Gram- 
])Ositive,  which  were  rarer. 

From  the  3 1st  December  began  a  definite  improvement. 
The  abdomen  became  slightly  depressible,  the  lumbar  curve 
diminished,  and  the  separation  of  the  incisors  now  amounted 
to  nearly  two  inches.  On  the  following  days  the  improvement 
was  very  marked,  the  abdomen  becoming  more  supple  ;  and 
about  the  7th  January  the  abdominal  wall  had  become  com- 
pletely relaxed,  even  when  the  patient  lay  completely 
extended ;  the  exaggeration  of  the  lumbar  curve  had 
completely  disappeared,  and  flexor  movements  of  the  trunk 
were  performed  with  ease.  On  the  15th  January  there  was 
no  longer  any  trace  of  the  abdominal  contracture,  and  the 
maxillary  separation  was  two  inches.  The  tendinous  reflexes 
of  the  left  leg  were  once  more  normal,  but  the  test  of  the 
left  plantar  cutaneous  reflex  still  determined  an  exaggerated 
contraction  of  the  tensor  fasciae  lata. 

The  patient  left  the  hospital,  cured,  on  the  1 5th  January. 
Seen  a  month  later,  he  was  in  perfect  health. 

In  this  observation  the  tetanus  was  therefore  con- 
fined to  the  abdomino-thoracic  muscles,  sparing  all 
the  remaining  groups  of  muscles,  excepting  the  masti- 
catory muscles,  which,  however,  were  only  very  slightly 
affected. 

The  tetanic  infection  entered  the  system,  as  M.  Marie 
justly  remarked,  by  the  wound  on  the  interior  and 
internal  face  of  the  thigh.  The  toxin  here  secreted 
ascended  along  the  branches  of  the  lumbar  plexus,  the 
femoro-cutaneous   nerve,  and  the  internal  cutaneous 


THE   ABDOMINO— THORACIC   TYPE        815 

nerve,  finally  reaching  the  corresponding  spinal  segment. 
Although  the  lower  limb  on  the  wounded  side  did  not 
exhibit  any  stiffness,  it  would  none  the  less  appear  to 
have  been  slightly  affected,  since  an  exaggeration  of 
the  tendinous  reflexes  was  noted. 

The  development  of  this  particular  form  recalls,  as 
we  shall  see,  that  of  the  early  or  late-appearing  localised 
forms  already  discussed. 

During  a  first  period,  in  short,  there  were  paroxysms 
of  painful  contractures  and  intermittent  jerks,  which 
in  this  case  were  localised  in  the  abdomen,  and  which 
spread  to  the  lower  limbs.  These  contractures  were 
accompanied  by  disquieting  respiratory  disorders, 
which  were,  however,  transitory,  and  might  very  likely 
be  attributed  to  the  extension  of  the  contracture  to  the 
muscles  innervated  by  the  intercostal  nerves. 

This  first  period  was  followed  by  a  phase  of  analgesic 
muscular  rigidity,  characterised  by  the  hardness  so 
peculiar  to  tetanus  ;  the  lower  half  of  the  trunk  of  the 
patient  observed  by  P.  L.  Marie  seemed  transformed 
into  marble. 

Lastly,  the  phase  of  progressive  and  lingering 
resolution  appeared. 

While  the  disease  was  passing  through  these  different 
periods  of  development  the  patient's  general  condition 
was  good ;  there  was  no  fever  and  no  marked  accelera- 
tion of  the  pulse.  There  was  nothing  to  remark  but 
the  hypersecretion  of  the  sweat-glands  :  a  sign  of  known 
significance  in  tetanus. 

The  pathogenesis  of  this  variety  is  like  that  of  the 
other  forms  of  localised  tetanus,  whether  early  or  late- 
appearing  ;  and  we  shall  presently  see  that  in  these 
cases  an  important  role  must  be  attributed  to  previous 
immunisation.     As  the  result  of  an  insufficient  initial 


816       THE  ABNORMAL  FORMS  OF  TETANUS 

preventive  injection,  or  rather  the  insufficiency  of  a 
single  preventive  injection  in  respect  of  a  prolonged  in- 
cubation or  a  secondary  reinfection,  the  tetanus  assumes 
a  clinical  aspect  which  is  local,  attenuated,  and  benign. 
The  incomplete  or  partial  immunity  conferred  limits 
the  development  of  the  tetanic  symptoms,  without, 
however,  preventing  the  fixation  of  the  toxin  in  certain 
medullary  territories. 

Finally,  the  prognosis  of  this  variety,  like  that  of  all 
the  partial  forms  of  tetanus,  is  benign. 


CHAPTER  VI 

ATTENUATED  FORMS  OF  TETANUS,  WITH  SLOW 
DEVELOPMENT  AND  PROLONGED  INCUBATION 

In  addition  to  the  monoplegic,  paraplegic,  and 
abdomino-thoracic  forms  which  we  have  already 
described,  we  think  it  proper  to  mention  the  attenuated 
forms,  with  slow  development  and  prolonged  incuba- 
tion, to  which  MM.  Claude  and  Lhermitte  have  called 
attention,  although  these  are  not  always  partial 
varieties  of  tetanus.  Our  principal  reason  for  mention- 
ing these  forms  is  that  the  disease  presents  such  peculiar 
features  that  these  may  well  deceive  an  observer  who 
is  not  sufficiently  forewarned. 

In  three  of  the  cases  reported  by  Claude  and  Lher- 
mitte, in  which  the  subjects  were  young,  hardy  soldiers, 
whose  usual  health  was  good,  tetanus  followed  upon 
extremely  superficial  wounds  of  the  limbs,  inflicted  by 
shell-splinters,  making  its  appearance  more  than  two 
months  later  than  the  date  of  the  wound.  There  was 
nothing  to  lead  one  to  expect  the  imminence  of  so 
serious  a  complication.  The  wounds,  indeed,  were  by 
no  means  important,  having  suppurated  only  slightly, 
and  being  completely  cicatrised,  in  two  of  these  cases,  a 
long  time  before  the  development  of  the  first  symptoms. 

These  latter  consist  of  a  slight  stiffness,  either  of  the 
muscles  of  the  wounded  limb,  or,  to  begin  with,  of  the 
masseters.  These  slight  contractures  permit  the  con- 
valescent to  perform  the  occupations  of  everyday  life 

817 


818       THE  ABNORMAL  FORMS  OF  TETANUS 

without  any  particular  difficulty  ;  then  they  become 
more  clearly  defined,  increasing  in  severity,  and  extend- 
ing to  other  areas.  At  this  stage  the  muscles  involved 
are  no  longer  those  of  the  wounded  limb,  and  the 
masseters,  but  the  musculature  of  the  neck,  and  some- 
times even  that  of  the  trunk.  Nevertheless,  the 
patients  are  still  able  to  walk  with  ease,  and  their 
general  condition  is  excellent ;  they  are,  as  a  rule,  re- 
garded as  suffering  from  neuropathic  contractures. 

When  we  examine  such  patients  we  are  at  once  im- 
pressed by  their  peculiar  and  rather  abnormal  facial 
expression.  The  features  appear  as  though  congealed, 
and  are  unusually  prominent ;  the  eyes  are  half  closed 
by  motionless,  narrowed  eyelids  ;  the  mouth  is  pinched, 
and  the  neck  is  rigid  ;  when  the  patient  is  stripped  one 
is  struck  by  the  prominence  of  the  sterno -mastoid  and 
cutaneous  muscles.  The  latter  are  rendered  even  more 
obvious  if  the  patient  be  told  to  open  his  mouth  ;  all 
the  muscles  of  the  face  and  neck  contract,  and  the 
slender  bundles  of  the  cutaneous  muscles  are  plainly 
outlined  under  the  skin.  The  patient  finds  it  difficult 
to  open  the  mouth  or  protrude  the  tongue.  The  latter 
is  thickly  coated,  and  is  marked  with  the  imprints  of  the 
teeth  ;  the  breath  is  fetid. 

The  same  hypertonia  may  be  observed  in  the  muscles 
of  the  lower  limbs,  whose  movements  are  slow  and 
painful  ;  the  upper  limbs  are  free  from  this  con- 
tracture, unless  the  initial  wound  is  situated  in  one  of 
them.  i 

As  a  general  thing  this  condition  of  muscular  hyper- 
tonia is  not  interrupted  by  paroxysms  of  contracture, 
as  in  the  classic  form  of  tetanus,  or  else  these  paroxysms 
are  extremely  transient  and  difficult  to  detect.  How- 
ever,  in   two   cases   Claude  and   Lhermitte  observed 


ATTENUATED  FORMS  OF  TETANUS         819 

paroxysmal  crises,  which  spread  to  a  large  number  of 
muscles,  and  which  were  extremely  painful. 

The  general  condition  remains  excellent,  and  the 
temperature  shows  no  departure  from  the  normal,  or 
exceeds  it  but  slightly. 

This  attenuated  form  of  tetanus  is  accompanied  by 
excessive  hyper-excitability  of  the  muscles  and  nerves 
to  electrical  stimulation,  and  an  exaggeration  of  the 
osseous  and  tendinous  reflexes,  with  clonus  of  the  foot 
and  saltation  of  the  patella.  In  the  neck,  percussion  of 
the  insertions  of  the  sterno -mastoids  or  the  cervical 
trapezius  causes  a  sharp  and  sudden  contraction  of  these 
muscles  ;  in  two  cases  percussion  of  the  zygoma  caused 
a  sudden  extensor  movement  of  the  head.  These  modi- 
fications of  the  reflexes  are  to  be  observed  in  the  mono- 
plegic  form  also,  and  in  speaking  of  the  latter  we  laid 
stress  upon  them  as  a  differential  sign  distinguishing 
tetanic  from  hysterical  contractures.  In  this  connec- 
tion also  the  hyper-excitability  of  the  muscles  and 
nerves  under  electrical  stimulation,  and  the  exaggera- 
tion of  the  osseous  and  tendinous  reflexes,  which  is 
observed  several  weeks  after  recovery,  constitute  in- 
dications of  the  greatest  importance  in  the  difficult 
differential  diagnosis  of  these  attenuated  and  late- 
appearing  forms  and  of  hysterical  contractures.  The 
attenuated  variety  of  tetanus,  whose  essential  features 
we  have  just  outlined,  constitutes  a  highly  individual 
form  of  the  disease,  by  reason  of  its  clinical  phenomena 
no  less  than  its  slow  development,  its  prolonged  incuba- 
tion, and  the  benign  character  of  its  prognosis. 


CHAPTER  VII 
ETIOLOGY    AND    PATHOGENESIS 

I.  Etiology 

Frequency. — The  generalised  form  of  tetanus,  whether 
early  or  late,  has  long  been  known  ;  it  is,  comparatively 
speaking,  a  frequent  affection.  Localised  tetanus,  on 
the  other  hand,  is  excessively  rare,  and  the  number 
of  definite  observations  is  very  limited.  It  is  enough 
to  refer  to  the  chief  observations  reproduced  in  this 
volume  to  realise  that  records  of  the  partial  forms, 
early  or  late-appearing,  are  infrequent  and  of  recent 
date.  This,  as  we  have  already  explained,  may  be 
largely  due  to  the  fact  that  the  partial  forms  of  tetanus 
were  for  a  long  time  misunderstood,  so  that  clinicians 
who  were  not  familiar  with  them  referred  the  localised 
contractures  which  they  observed  as  following  trau- 
matisms to  another  cause.  There  is  no  need  to  read 
the  old  writers  to  realise  the  truth  of  this  assertion. 
In  Follin's  Traite  de  Pathologie  externe,  published  in 
1867,  that  writer  described,  under  the  name  of  second- 
ary traumatic  spasms,  an  affection  very  similar  to  that 
which  we  have  described  :  traumatisms  were  followed 
by  convulsions  confined  to  one  member,  with  absence 
of  trismus,  and  a  fatal  termination.  Probably  Follin 
had  in  his  possession  documents  which  enabled  him  to 
sketch  the  history  of  these  traumatic  spasms,  and  these 
latter,  which  by  us  are  regarded  as  partial  forms  of 

820 


ETIOLOGY  AND  PATHOGENESIS  821 

tetanus,  are  doubtless  less  rare  than  might  be  supposed. 
Their  rarity,  however,  is  explained  by  the  undoubted 
fact  that  certain  peculiar  conditions  are  required  for 
their  development,  and  also  by  the  fact  that  under 
certain  conditions  attenuated  toxins  may  be  developed, 
as  we  shall  see  when  discussing  the  question  from  the 
pathogenic  standpoint. 

Cause. — The  cause  of  localised  tetanus  of  the 
members  consists,  as  in  all  the  other  varieties  of  the 
disease,  in  the  introduction  into  the  system  of  the  toxins 
secreted  by  Nicola ier's  bacillus,  with  which  a  wound  has 
been  infected. 

Causal  Agent. — The  bacillus  of  tetanus  was  dis- 
covered in  1883  by  Nicolaier,  in  the  pus  of  animals  which 
he  had  rendered  tetanic  by  inoculation  with  small 
quantities  of  earth. 

Kitasato  first  isolated  and  cultivated  it,  and  by  de- 
monstrating that  inoculation  with  cultures  of  the  germ 
gave  rise  to  tetanus  he  proved  its  specific  character. 
The  important  labours  of  Vaillard,  Vincent,  and  Rouget 
determined  the  conditions  under  which  tetanus  is  able 
to  develop.  Finally,  the  study  of  the  toxin  secreted  by 
the  tetanic  bacillus  enabled  Roux  and  Vaillard  to  obtain 
a  serum  whose  preventive  action  no  longer  calls  for 
proof. 

Morphology. — In  the  pus  of  the  tetanic  wound  the 
bacillus  occurs  in  the  form  of  a  rather  slender,  elongated 
rod,  the  ends  of  which  are  not  rounded.  It  measures, 
on  an  average,  4  /a  in  length  and  0*3  /a  to  0-4  /a  in 
thickness.     It  is  usually  devoid  of  spores. 

In  cultures  its  aspect  differs  according  to  the  age 
of  the  latter. 

During  the  first  few  hours  of  its  development  in 
bouillon  it  presents  the  same  form  as  in  pus  ;  but  at  the 


822       THE  ABNORMAL  FORMS  OF  TETANUS 

end  of  eight  hours  it  begins  to  sporulate.  The  tetanic 
bacillus  then  appears  as  a  slender  rod  bearing  upon  one 
of  its  extremities  a  spherical,  refracting  spore,  which 
gives  the  germ  the  form  of  a  pin.  At  the  end  of  a  few 
days  all  the  bacilli  have  sporulatcd.  About  the  tenth 
day  the  bacillus  proper  atrophies,  and  later  still  it  dis- 
appears from  the  culture,  leaving  only  the  spores. 

Mobility. — Examined  in  the  fresh  state,  in  the  absence 
of  oxygen,  the  bacillus  which  has  not  yet  sporulatcd  is 
slightly  mobile.  Its  movements  are  slow  and  sinuous. 
As  soon  as  the  spore  has  formed  this  mobility  disappears. 

Staining. — The  basic  aniline  dyes  will  stain  the 
tetanus  bacillus  satisfactorily.  The  sporulatcd  bacilli 
take  the  stain  only  in  their  bacillary  portion  ;  as  for  the 
spore,  only  the  outline  is  stained,  the  centre  remaining 
colourless.  To  stain  the  central  portion  of  the  spore 
one  must  employ  the  special  methods  for  the  staining  of 
spores  (Moeller's  process,  for  example).  The  tetanus 
bacillus  is  Gram-positive. 

Lastly,  before  the  spore  has  formed  the  bacillus  is 
provided  with  numerous  vibratory  cilia,  which  are 
attached  laterally. 

Cultures. — The  tetanic  bacillus  is  readily  cultivated 
in  anaerobic  media,  but  cannot  support  the  presence  of 
any  very  appreciable  quantity  of  oxygen.  The  usual 
media  may  be  employed,  provided  they  are  prepared 
with  fresh  bouillon  (Kitasato).  It  does  not  readily 
multiply  in  media  with  albuminous  bases,  but  cultures 
made  in  rabbit  serum  are  extremely  virulent. 

In  bouillon,  after  twenty-four  hours,  a  homogeneous 
turbidity  is  observed,  which  continues  for  some  days  ; 
about  the  fourteenth  or  fifteenth  day  the  culture  sinks 
to  the  bottom  of  the  tube  and  the  liquid  becomes  clear. 
From  the  first  day  bubbles  of  gas  are  seen  on  the  surface. 


ETIOLOGY  AND  PATHOGENESIS  823' 

These  cultures  give  off  a  disagreeable  odour,  recalling 
that  of  burnt  horn. 

On  gelatine  cultures  obtained  by  deep  punctures  (to 
avoid  the  deterrent  effect  of  oxygen)  and  maintained  at 
a  temperature  of  20°  C.  the  cultures  make  their  appear- 
ance about  the  fifth  day.  In  the  region  of  the  puncture 
cloudy  spots  are  formed,  from  which  fine  needle-like 
formations  extend  in  a  perpendicular  direction.  These 
cultures  spread  more  and  more,  until  about  the  tenth 
day  the  gelatine  liquefies  in  the  lower  portion  of  the 
tube,  remaining  intact  in  the  upper  portion. 

The  isolated  colonies  occur  in  the  form  of  tiny  spheres, 
of  a  cloudy  appearance,  from  which  grow  tufts  of  fine 
needle-like  filaments  ;  these  colonies  are  surrounded 
by  tiny  bubbles  of  gas.  When,  on  the  tenth  day,  the 
gelatine  liquefies,  the  colonies  appear  as  tuft-like 
formations  swimming  in  a  round  cupule  of  liquefied 
gelatine. 

On  agar  the  culture  is  cloudy,  without  any  very  dis- 
tinctive characteristics.  The  medium  is  broken  up  by 
numerous  bubbles  of  gas. 

On  potato  the  development  is  poor. 

In  milk  the  cultures  develop  readily,  and  the  medium 
is  not  coagulated. 

Biological  Properties. — Vitality. — The  spores  of  the 
tetanus  bacillus  are  highly  resistant.  Heated  in  a 
closed  flask  in  a  moist  medhim,  they  will  support  boiling 
for  four  or  five  minutes  without  perishing  ;  while  they 
resist  a  temperature  of  80°  C.  for  as  long  as  six  hours. 

Dried  in  an  albuminous  medium  (serum,  blood,  etc.), 
Mai  jean  found  that  they  frequently  survived  heating 
to  40°  C.  in  steam,  under  pressure,  for  fifteen  minutes. 

If  protected  from  the  air  and  light,  their  vitality 
persists  for  several  years.     Mingled  with  blood  or  pus, 


834       THE  ABNORMAL  FORMS  OF  TETANUS 

and  sheltered  from  the  Hght,  they  retain  their  virulence 
for  a  long  time. 

Mocard  has  found  them  living  after  a  lapse  of 
eighteen  months  upon  articles  which  had  been  em- 
ployed in  connection  with  colts  which  had  died  of 
tetanus. 

Eiselberg  succeeded  in  giving  tetanus  to  an  animal 
by  inoculating  it  with  a  splinter  which  had  been  ex- 
tracted from  the  hand  of  a  tetanus  patient,  and  had 
been  kept  for  two  and  a  half  years  in  a  cupboard. 

Formation  of  Indol. — Cultures  in  bouillon  are  rich  in 
indol. 

Formation  of  Gas. — The  gases  which  are  given  off  by 
the  cultures  are  nitrogen,  hydrogen,  and  hydrocarbons. 

Hemolysin.- — According  to  Ehrlich  and  Madsen, 
filtered  cultures  of  tetanic  bacilli  contain  a  substance 
differing  from  the  toxin,  which  dissolves  the  red  blood 
corpuscles  of  the  majority  of  the  domestic  animals. 
This  tetanolysin  is  very  unstable  ;  it  is  rapidly  destroyed 
if  heated  to  .50°  C.  (in  twenty  minutes)  ;  exposed  for 
five  hours  to  a  temperature  of  20°  C.  it  loses  half  its 
power,  only  a  temperature  of  0*0°  C.  enabling  it  to 
retain  its  activity  for  twenty-four  hours.  Tetanolysin 
is  precipitated  by  sulphate  of  ammonia.  The  resulting 
powder,  if  desiccated,  keeps  for  a  long  time. 

Agglutinability. — The  bacillus,  as  we  saw  when  con- 
sidering the  diagnosis  of  tetanus,  is  not  agglutinated  by 
the  serum  of  a  human  being  or  an  animal  suffering 
from  tetanus.  With  the  serum  of  a  horse  vaccinated 
against  the  tetanic  toxin  agglutination  may  be  effected 
by  very  minute  proportions  :  1  in  2000  and  even  1  in 
5000  (Courmont). 

Experimental  Pathogenic  Action.  —  Animals,  in 
general,  are  susceptible  to  the  tetanic  infection.     In  the 


ETIOLOGY  AND  PATHOGENESIS  825 

laboratories  the  mouse,  rat,  and  guinea-pig  are  em- 
ployed by  preference  ;  the  dog  is  highly  refractory, 
while  the  domestic  fowl  and  the  pigeon  are  completely 
so. 

To  obtain  experimental  tetanus  it  suffices  to  inject 
under  the  skin  or  into  the  muscles  of  the  thigh  of  a 
susceptible  animal  a  small  quantity  of  some  medium 
containing  tetanic  bacilli  or  spores. 

Inoculation  with  Tetaniferous  Pus  or  Soil. — Pus 
collected  from  a  tetanic  wound  is  inoculated  under  the 
skin  of  an  animal.  At  the  point  of  inoculation  a  more 
or  less  extensive  tumefaction  is  produced.  Three  or 
four  days  later  contractures  appear,  first  in  the  neigh- 
bourhood of  the  region  inoculated,  but  later  they 
become  generalised  ;  convulsive  attacks  occur  as  a 
result  of  the  slightest  excitation.  The  animal  succumbs 
thirty-six  to  forty-eight  hours  after  the  onset  of 
tetanus. 

At  the  autopsy  a  purulent  centre  is  discovered  at  the 
point  of  inoculation  ;  this  contains,  in  addition  to  the 
germs  of  suppuration,  a  few  specimens  of  tetanus  bacilli. 
This  pus  may,  with  success,  be  employed  to  inoculate 
other  animals,  but  after  three  such  passages  the  results 
are  negative  (Vaillard). 

The  viscera  appear  normal,  except  for  a  passive 
pulmonary  congestion  due  to  pre-mortal  dyspnoea.  By 
injecting  tetaniferous  soil  under  the  same  conditions, 
the  same  results  are  obtained  ;  but  at  the  point  of 
inoculation  a  dry  eschar  is  often  produced,  or  a  pseudo- 
membranous exudate  due  to  the  existence  of  associated 
germs. 

InoculatioJi  with  Pure  Cultures. — Subcutaneous,  intra- 
muscular, intravenous,  intraperitoneal,  or  subdural 
inoculation    gives    rise    to    a    typical    tetanus.     The 


826       THE  ABNORMAL  FORMS  OF  TETANUS 

introduction  of  the  germ  by  the  digestive  tract  produces 
no  result. 

Young  cultures,  as  a  rule,  are  not  very  tetanigenous, 
as  they  contain  but  little  toxin. 

It  is  interesting  to  note  that  in  all  cases,  no  matter 
what  the  mode  of  inoculation,  the  blood  remains  sterile. 

Tetanus  Toxin. — The  bacillus  does  not  become 
generalised.  The  general  signs  are  due  to  the  action 
of  a  poison  elaborated  by  the  germ  and  diffused 
throughout  the  organism.  The  existence  of  this  toxin 
was  demonstrated  for  the  first  time  in  1890,  by  Kund 
Faber  ;  it  has  been  very  fully  investigated  by  Vaillard 
and  Vincent. 

Method  of  Preparation. — The  tetanus  bacillus  is 
inoculated  into  a  spherical  flask  containing  fresh 
peptonised  bouillon.  This  is  placed  in  an  incubator, 
which  is  kept  at  a  temperature  of  37°  C.  for  eighteen  to 
twenty  days.  It  is  then  filtered  through  a  Chamber- 
land  filter  ;  the  filtrate  obtained  exhibits  an  alkaline 
reaction,  and  gives  off  the  characteristic  odour  ;  it  is 
highly  toxic,  for  a  dose  of  '001  c.c.  kills  a  mouse. 

Nature  and  Properties  of  {he  Toxin. — The  earliest 
investigations  gave  rise  to  the  hypothesis  that  the 
tetanic  toxin  was  a  ptomaine  (Brieger).  Others  attri- 
buted to  it  the  properties  of  the  alkaloids.  Ehrlich 
considered  that  it  was  composed  of  several  substances  : 
one  being  tetano-spasmin,  an  energetic  convulsive 
agent,  and  another  tetano-lysin,  possessing  no  tetan- 
ising  properties.  In  reality,  the  tetanic  toxin  may  be 
likened  to  the  diastases.  Like  them,  it  is  greatly 
modified  by  exposure  for  half-an-hour  to  a  temperature 
of  65°  C,  and  exposure  for  three  hours  to  a  temperature 
of  80°C.  kills  it. 

In  a  closed  vessel,  protected  from  light  and  air,  it 


ETIOLOGY  AND  PATHOGENESIS  827 

may  retain  its  toxic  power  for  four  months.  Exposed 
to  the  air  for  one  month,  it  loses  a  great  part  of  its 
activity  ;  and  the  action  of  the  air  is  greatly  acceler- 
ated by  the  simultaneous  action  of  sunlight. 

Evaporated  in  a  vacuum  over  sulphuric  acid,  at 
ordinary  temperatures,  the  toxin  is  reduced  to  a  brown 
residuum,  amorphous  and  highly  toxic.  If  absolute 
alcohol  be  added,  the  latter  dissolves  a  portion  of  the 
residuum,  which  after  evaporation  is  non-toxic.  The 
portion  insoluble  in  alcohol  is  freely  soluble  in  water, 
and  readily  produces  tetanus  in  animals.  The  dialysis 
of  this  tetanic  substance  is  a  rather  slow  process. 
Lastly,  like  the  diastases,  the  tetanus  toxin  adheres  to 
the  precipitates  of  phosphate  of  calcium  and  aluminium 
which  are  thrown  down  from  it  upon  the  addition  of 
chloride  of  calcium  ;  if  these  are  carefully  washed  in 
sterile  water  and  inoculated  under  the  skin  of  the 
guinea-pig,  the  latter  contracts  tetanus. 

According  to  Courmont  and  Doyon  the  tetanus  toxin 
is  merely  a  soluble  ferment,  devoid  of  toxicity  in  itself, 
but  able  to  cause  a  fermentation  of  certain  substances 
in  the  organism  ;  the  true  toxin  results  from  this.  This 
interpretation  has  not  been  accepted  by  other  writers. 
Lastly,  the  toxin  may  sometimes  be  found  in  the  blood 
of  tetanic  patients. 

The  Mode  of  Action  of  the  Toxin. — The  tetanic  toxin 
is  a  poison  of  the  nervous  system,  its  special  affinity  for 
the  latter  having  been  demonstrated  by  the  classical 
experiment  of  Wassermann  and  Takaki.  The  toxin 
was  mixed  with  pulped  cerebral  matter,  and  subjected 
to  centrifugalisation.  The  resulting  liquid  was  devoid 
of  toxicity,  although  the  toxin  was  not  destroyed. 
Roux  and  Borrel  proved  that  tt  was  fixed  and 
immobilised    by    the    nervous     system,    and     then, 


82S       THE  ABNORMAL  FORMS  OF  TETANUS 

accordingto  Metchnikov,  absorbed  and  digested  by  the 
leucocytes. 

The  investigations  of  A.  Marie  show  that  the  toxin 
attacks  the  nervous  system  in  two  ways.  One  portion 
of  it  passes  into  the  circulation,  where  it  is  fixed  by  the 
nerve-cells  ;  the  other  portion  is  absorbed  by  the  peri- 
pheral nervous  filaments,  which  gradually  carry  it, 
along  the  axis  cylinders,  to  the  nervous  centres. 

Habitat  of  the  Tetanic  Bacillus. — Now  that  we  have 
considered  the  tetanic  bacillus  and  its  toxin,  we  have 
still  to  inquire  into  the  habitat  of  the  bacillus — -a 
question  of  particular  importance  from  the  purely 
hygienic  point  of  view. 

Very  often  the  occasional  circumstances  of  the 
traumatism  throw  light  upon  the  etiology  of  the  disease. 
For  the  rest,  the  following  remarks  apply  equally  to  all 
the  clinical  varieties  of  tetanus : 

The  Soil.- — AH  authorities  are  at  present  in  agreement 
as  to  the  tellaric  origin  of  the  tetanus  bacillus.  The 
spores  of  the  tetanus  bacillus  are  frequently  found  in 
the  excrement  of  the  horse.  It  is  already  some  time 
since  Sanchez-Toledo  and  Veillon  proved  that  the 
tetanus  bacillus  is  a  frequent  inmate  of  the  intestine  of 
the  herbivora,  and  in  particular  of  the  horse.  The 
bacillus,  accordingly,  occurs  principally  on  the  surface 
of  the  soil.  At  a  depth  of  twelve  inches  it  is  rarer ; 
on  the  other  hand,  it  swarms  in  manure,  or  on  dung- 
hills. In  the  present  war  the  infection  may  be  derived 
from  the  wound  itself,  which  is  contaminated  by  dust, 
or  even  by  particles  of  earth  (owing  to  the  ricochet  of 
bullets  or  shell-splifiters).  It  may  also  occur  directly, 
at  the  moment  when  the  wounded  man  falls  to  the 
ground,  or  while  he  is  lying  on  it.  Infection  may  also 
be  due  to  clothing  covered  with  earth  or  mud  which 


ETIOLOGY  AND  PATHOGENESIS  829 

contains  tetanic  germs.  Or  again,  infection  may  be 
directly  effected  when  the  wounded  man  crawls  over 
the  ground  in  search  of  cover.  It  is  probable  that  the 
great  frequency  of  tetanus  in  the  present  war  is  due  to 
the  extensive  earthworks  necessitated  by  trench  fighting. 

It  must  be  remembered  that  the  soil  contains  more 
or  fewer  bacilli  in  different  regions.  There  are  tetani- 
genous  centres — that  is,  centres  where  tetanus  is  more 
frequent  than  elsewhere.  This  fact  has  long  been 
noted  by  veterinary  surgeons,  and  is  abundantly  proved 
by  a  survey  of  the  cases  of  tetanus  which  have  occurred 
during  the  present  war.  Belgium  and  the  regions  at 
present  invaded  are  said  to  be  tetanus  countries.  Dr 
Paul  Guillon  states  that  the  Marne  contains  tetanic 
belts — that  is,  districts  where  tetanus  frequently  occurs 
— while  elsewhere  it  is  of  infrequent  occurrence.  It  has 
been  stated  also  that  the  soil  of  the  Aisne  valley  con- 
tains far  more  tetanic  germs  than  the  soil  of  the  sur- 
rounding districts.  According  to  Bowby,  tetanus  was 
less  frequent  after  the  battles  around  Ypres  than  in  the 
valley  of  the  Aisne.  Possibly  the  germs,  like  the  flora, 
are  affected  by  conditions  arising  from  the  mineral 
composition  of  the  soil.  The  rich  clay  of  Flanders  is 
perhaps  less  propitious  to  the  cultivation  or  dissemina- 
tion of  tetanic  spores  than  the  dusty,  calcareous  soil  of 
Champagne.  Let  us  note,  lastly,  that  it  is  said  that  in 
England  wounds  are  infected  chiefly  by  staphylococci 
and  streptococci,  while  in  France  one  finds  principally 
anaerobic  microbes,  the  tetanus  bacillus,  the  bacillus  of 
gas  gangrene,  and  the  bacillus  of  malignant  oedema 
(Dutertre). 

The  existence  of  soils  rich  or  poor  in  tetanic  spores 
has  been  scientifically  verified.  There  are  no  pure 
cultures  of  tetanic  germs  in  the  soil ;   perhaps  it  is  to 


830       THE  ABNORMAL  FORMS  OF  TETANUS 

the  association  of  the  germ  with  other  microbes  that 
the  extraordinary  virulence  of  the  tetanus  bacillus  is 
due,  when  found  in  mixed  infections.  The  importance 
of  these  microbic  associations  has  long  been  known. 
Because  of  these  associations,  or  the  presence  of  foreign 
bodies,  or  again  as  a  result  of  the  attrition  or  destruc- 
tion of  tissues,  the  phagocytes,  being  otherwise  em- 
ployed, fail  to  prevent  the  microbic  invasion.  These 
associated  microbes  favour  the  tetanic  infection. 

Straw. — We  must  not  fail  to  remark  that  while 
contact  with  the  soil  is  dangerous,  contact  with  straw 
which  has  been  more  or  less  contaminated  by  the  ground 
upon  which  it  has  lain  may  also  become  a  source  of 
infection. 

The  manner  in  which  the  wound  is  inflicted. — The 
foregoing  considerations  explain  the  varying  frequency 
of  this  complication  according  to  the  cause  of  the  wound 
and  the  manner  in  which  it  is  inflicted.  It  is  obvious 
that  there  is  every  probability  that  the  bullet  which  has 
not  ricochetted  carries  no  tetanic  spores  with  it.  This 
is  not  the  case  with  splinters  of  percussion  shells  ;  the 
shell  having  burst  in  the  ground,  its  splinters  almost 
invariably  carry  particles  of  earth  with  them,  as  does 
the  ricochetting  bullet.  Doubtless  in  pursuance  of 
this  idea  it  has  been  said  that  tetanus  almost  always 
occurs  as  a  result  of  wounds  caused  by  artillery 
projectiles. 

Any  extensive  wound  of  the  soft  tissue  should  be 
regarded  as  suspect. 

Bullet  wounds  also  yield  a  high  percentage  of 
tetanus  (Dutertre). 

Among  129  cases  of  tetanus  Bazy  cites,  from  the 
German  periodicals,  9  cases  due  to  rifle  bullets. 

Fragments  having  plane  surfaces  are  more  likely  to 


F/nOLOGY  AND  PATHOGENESIS!  831 

drag  shreds  of  clothing  into  wounds  than  pointed 
bullets,  which  simply  perforate  the  clothing  when  they 
strike  point  foremost ;  and  we  have  seen  that  fragments 
of  clothing  contaminated  by  the  soil  may  very  well  be 
the  vehicles  of  tetanic  spores.  Although  it  is  difficult 
to  forecast  tetanus,  the  manner  in  which  the  wound  has 
been  contaminated,  and  above  all  the  carrying  of  shreds 
of  clothing,  with  a  mixture  of  grains  of  sand  and  little 
stones,  into  the  wound,  are  valuable  indications. 

The  situation  of  the  wound  is  also  an  important  factor, 
as  will  readily  be  understood.  Wounds  of  the  ex- 
tremities are  most  liable  to  come  into  direct  contact 
with  the  soil,  and  they  are  therefore  most  readily  in- 
fected. The  wounded  man,  in  falling,  throws  his  hands 
forward  as  far  as  possible  ;  the  man  wounded  in  the  leg 
or  foot  bears  a  wound  peculiarly  exposed  to  the  dust 
rising  from  the  soil. 

Some  statistics  of  Madelung's  bearing  upon  the 
situation  of  the  wound  by  which  infection  enters  are 
significant  in  this  connection.  In  166  cases  of  tetanus 
the  head  was  wounded  five  times  ;  in  8  cases  the  trunk 
alone  was  wounded  ;  in  50  cases  the  lower  extremities 
only  ;  while  in  103  cases  there  were  multiple  wounds  : 
wounds  of  the  upper  and  lower  extremities.  In  no 
case  did  tetanus  result  from  a  pulmonary  wound : 
perhaps  because  of  the  richness  in  oxygen  of  the 
pulmonary  tissues.  The  predominance  of  wounds  of 
the  lower  extremities  has  long  been  known. 

The  Nature  of  the  Wound. — This,  perhaps,  is  not  so 
important,  in  respect  of  the  genesis  of  tetanus,  as  some 
would  have  it.  Nevertheless,  it  is  enough  to  examine 
the  statistics,  and  we  realise  that  tetanus  is  encountered 
more  particularly  in  cases  where  there  is  great  destruc- 
tion of  muscular  tissue,  and  opening  of  articulations, 


333       THE  ABXORMAL  FORM.i  OF  TETANUS 

with  abundant  suppuration.  ^  In  many  of  these  wounds, 
moreover,  at  all  events  in  this  war,  either  shell-splinters 
are  found,  or  fragments  of  straw  contaminated  by  the 
soil,  or  shreds  of  uniform,  with  tetanic  spores. 

We  have  every  justification  for  saying  that  while 
bullet  wounds  may  give  rise  to  tetanus,  suppurating 
wounds  of  the  lower  extremities  are  predominantly 
those  which  are  most  frequently  complicated  by  a 
generalised  or  localised  tetanic  infection. 

Adjuvant  Factors. — Atmospheric  Conditions. — Heat  is 
a  factor  which  favours  the  tetanic  infection.  We  know 
that  when  guinea-pigs  inoculated  with  tetanic  spores, 
without  toxin,  are  placed  in  an  incubator  heated  to 
40°  C.  for  two  or  three  days,  they  contract  a  super-acute 
tetanus,  developing  as  a  sphlancnic  tetanus,  the 
bacillus  being  generalised  through  all  the  tissues.  In 
the  case  of  guinea-pigs  infected  thirty  to  sixty  days 
previously,  and  then  placed  in  the  incubator  under  the 
same  conditions,  tetanus  is  still  produced.  These  facts 
are  explained  by  the  destruction  of  the  phagocytes 
under  the  influence  of  these  high  temperatures,  this 
permitting  the  germination  of  the  spores,  which  were 
immobilised  in  the  leucocytes. 

Cold. — Cold  is  also  regarded  as  a  factor  favouring  the 
appearance  of  tetanus,  so  care  should  be  taken  that  a 
man  seriously  wounded  does  not  become  chilled. 

Humidity  is  regarded  by  Schultze  as  a  factor  favour- 
ing the  development  of  tetanus.  We  do  not  believe  in 
the  existence  of  this  atmospheric  influence,  for  the 
microbes  occurring  in  dust  are  disseminated  every- 
where in  dry  weather,  and  find  the  conditions  necessary 
to  their  development  in  the  moisture  of  wounds. 

Secondary  Infection. — The  part  played  by  microbic 
associations  in  the  production  of  tetanus  is  considerable. 


ETIOLOGY  AXD  PATHOGENESIS  933 

This   is  proved  by   the   experiment   conducted   by 
Vaillard  and  Vincent. 

Under  the  skin  of  the  guinea-pig  were  injected  spores 
free  from  toxin,  incapable  of  producing  tetanus  alone  ; 
at  the  same  time  0-5  c.c.  of  a  culture  of  microbacillus 
prodigiosus  was  injected.  Thirty- two  hours  later  a 
mortal  tetanus  developed.  It  may  be  that  the  phago- 
cytes seized  upon  the  latter  germ,  ignoring  the  tetr.nic 
spores,  which  were  able  to  germinate  at  leisure  and 
secrete  their  toxin.  This  fact  explains  how  soil  which 
is  extremely  poor  in  tetanic  spores  may  cause  tetanus 
in  man  or  beast,  thanks  to  the  common  microbes  which 
it  contains,  which  play  an  important  part  in  favouring 
the  development  of  tetanus.  This  part,  however,  is 
not  common  to  all  germs.  Vaillard  and  Vincent  were 
ifnable  to  produce  tetanus  when  the  associated  microbe 
was  a  staphylococcus,  a  streptococcus.  Bacillus  subtilis, 
or  the  pneumo  bacillus.  In  order  that  a  tetanic  product 
may  produce  tetanus,  the  presence  is  necessary  : 

1.  Of  the  tetanic  bacillus,  or  tetanic  spores. 

2.  Of  a  micro-organism  capable  of  favouring  its 
germination. 

The  Action  of  Chemical  Substances. — According  to 
Vincent,  the  salts  of  quinine  act  in  the  same  manner  as 
lactic  acid,  appearing  to  favour  the  tetanic  infection 
when  injected  simultaneously  with  spores  without 
toxin.  Moreover,  if  in  the  case  of  guinea-pigs  which 
have  been  inoculated  with  spores  some  days  previously, 
and  have  remained  healthy,  a  quinine  salt  be  injected 
under  the  skin,  tetanus  breaks  out,  and  the  tetanic 
bacillus,  which  had  remained  in  a  latent  condition, 
behaves  as  though  attracted  to  the  point  where 
the  quinine  is  injected,  multiplies  there  profusely,  and 
becomes  generalised,  even  throughout  the  viscera.     We 


834        THE  ABNORMAL  FORMS  OF  TETANUS 

shall  presently  discuss  the  importance  of  this  fact  from 
the  standpoint  of  prophylactic  hygiene. 

Direct  Contact. — Lastly,  there  may  be  a  danger  of 
transmitting  tetanus  from  one  patient  to  another, 
hence  the  necessity  of  isolating  tetanus  patients  and 
appointing  special  attendants.  The  present  war  has 
given  us  several  confirmations  of  this  etiological  hypo- 
thesis. Dutertre  records  the  history  of  three  wounded 
men,  who  at  Douai  were  placed  in  adjacent  beds,  and 
were  attacked  by  tetanus.  There  is  also  the  case  of  five 
wounded  men  who  were  put  to  bed  in  the  same  room, 
one  beside  another.  Three  of  them  had  been  infected 
in  action  ;  forming  part  of  the  same  regiment,  and 
wounded  at  the  same  time,  they  had  lain  side  by  side 
on  the  battle-field.  The  three  first  gave  tetanus  to  the 
two  others,  by  touching  their  dressings  with  their  hands. 

We  must  add  that  the  transmission  of  tetanus  may 
also  be  effected  by  flies. 

II.  Pathogenesis 

The  history  of  the  atypical  forms  of  tetanus  raises 
an  interesting  pathogenic  question.  It  seems  that  in 
localised  tetanus  preventive  serotherapy  preserves  the 
bulbar  centres.  The  infection  seems  to  be  attenuated 
by  incomplete  serum  immunisation.  We  know, 
experimentally,  that  an  injection  of  toxin  sufficient  to 
provoke  a  generalised  form  of  tetanus  will  give  rise  to 
an  atypical  form  only  if  followed  by  an  injection  of 
serum  within  a  period  not  exceeding  two  hours.  In 
certain  cases  also  there  may  be  question  of  bacilli  less 
virulent  than  normally  ;  the  attenuated  toxins  would 
then  act  only  upon  the  nerves  of  the  injured  member 
(monoplegic  tetanus),  or  on  one  medullary  segment 


ETIOLOGY  AND  PATHOGENESIS  835 

(paraplegic  tetanus,  tetanus  of  the  abdomino- thoracic 
type). 

This  hypothesis  is  supported  by  the  majority  of 
those  writers  who  have  recorded  cases  of  partial  tetanus, 
and  in  particular  by  Pozzi,  Carnot,  and  Laval  :  and  it 
is  all  the  more  probable  in  that  we  are  able,  by  injecting 
a  weak  dose  of  culture  into  an  animal,  to  provoke  con- 
tractures localised  to  the  infected  limb.  In  short,  an 
atypical  form  of  tetanus  results.  Thus  if  we  inject,  into 
the  hind  leg  of  a  guinea-pig,  an  extremely  weak  dose  of 
tetanic  toxin,  incapable  of  producing  a  fatal  result,  we 
obtain  a  typical  local  tetanus  which  is  strictly  confined 
to  the  inoculated  limb.  The  contracture  is  rigid,  and 
persists  for  some  weeks.  The  action  of  the  toxin  does 
not  proceed  beyond  the  spinal  cord  segment  innervating 
the  inoculated  limb,  and  exhausts  itself  there ;  it  does 
not  attack  other  nervous  centres.  The  comparison  of 
such  an  experiment  with  actual  clinical  examples  is 
always  of  the  greatest  interest.  Klemm  does  not  hesi- 
tate to  assert  that  if  we  were  carefully  to  observe 
wounded  men  who  develop  tetanus  from  the  first,  we 
should  always  find  an  initial  local  contracture  ii} 
the  region  of  the  wound  which  admitted  the  tetanic 
infection. 

As  we  have  already  remarked,  in  connection  with  our 
communication  to  the  Academy  of  Medicine  in  January,* 
1916  (Obs.  XVI.),  there  are  two  factors  which  enable 
us  to  explain  localisation,  early  or  late,  in  a  wounded 
limb  or  a  given  anatomical  region.  These  are,  on  the 
one  hand,  an  incomplete  preventive  serotherapy ;  on 
the  other,  the  existence  of  bacilli  of  a  low  degree  of 
virulence,  few  in  numbers,  and  secreting  attenuated 
toxins.  These  two  factors  may  act  in  conjunction  or 
singly. 


836       THE  AByOEMAL  FORMS  OF  TETAXUS 

Another  question  arises  :  What  is  the  mechanism 
by  which  a  preventive  injection  locaHses  the  tetanic 
infection  ?  Is  the  virulence  of  the  toxin  secreted 
neutralised  or  attenuated,  or  does  the  preventive  serum 
place  the  nervous  system  in  a  condition  of  defence,  en- 
abling it  to  check  the  ascendant  progress  of  the  toxin  ? 
This  latter  conception  is  plausible,  and  it  seems  highly 
probable,  if  we  consider  that  the  serum  is  preven- 
tive rather  than  curative,  that  the  antitoxin,  the 
moment  it  is  injected,  checks  the  further  production  of 
toxin,  or,  rather,  destroys  it  as  soon  as  produced  in  the 
region  of  the  wound. 

The  secretion  of  the  toxins  being  thus  arrested,  when 
the  quantity  acting  upon  the  nervous  system  is  the 
result  only  of  a  short  lapse  of  time — the  period  dividing 
the  moment  of  the  wound  from  the  moment  of  the 
injection — the  dose  in  circulation  is  too  small  to  become 
widely  diffused,  and  to  act  directly  upon  the  entire 
nervous  system  ;  it  localises  its  action  upon  the  nerves 
of  the  wounded  limb  and  the  corresponding  spinal 
segments. 


CHAPTER  VIII 

DEVELOPMENT   AND    PROGNOSIS 

Development. — Generally  speaking,  the  localised  and 
atypical  forms  of  tetanus  and  the  partial  forms  of 
tetanus  of  the  limbs  are  characterised  by  a  slow  develop- 
ment, with  a  tendency  toward  recovery.  Owing  to  the 
long  duration  of  the  different  periods  of  the  infection, 
sequelae  may  occur,  veritable  complications,  which  are 
usually  of  a  transitory  nature.  Sometimes,  however, 
these  sequelae  are  permanent,  if  the  physician  is  not 
careful  to  guard  against  them  or  combat  them  directly 
they  make  their  appearance. 

The  development  of  the  localised  forms  of  tetanus  is 
sub-acute  or  chronic.  It  does  not  appear,  to  judge 
from  the  pathogenic  conceptions  expressed  in  the  fore- 
going chapters,  that  an  acute  local  tetanus  can  exist. 

It  is  true  that  Vincent  and  Wilhem  published,  under 
the  title  of  Localised  Tetanus,  details  of  a  case  of  tetanus 
which  was  confined  to  the  lower  limbs,  with  contrac- 
tures in  hyper-extension,  in  which  death  occurred  in 
twenty-four  hours,  as  the  result  of  grave  pulmonary 
phenomena  which  were  shown  by  an  intense  polypnoea. 
If  this  observation  be  analysed  it  plainly  appears  that 
the  patient  exhibited  the  signs  of  a  tetanic  infection 
which  should  rather  have  been  classified  as  a  super- 
acute  generalised  form  of  tetanus,  in  which  the  toxin 
was  rapidly  diffused  throughout  the  system. 

Owing    to    an    extremely    rapid    development,    the 

837 


838      THE  ABNORMAL  FORMS  OF  TETANVS 

clinical  signs  had  no  time  to  reveal  themselves  ;  the 
symptomatology  therefore  remained  that  of  the  more 
attenuated  forms,  giving  the  appearance  of  being 
localised. 

As  regards  the  monoplegic  and  paraplegic  forms, 
whether  early  or  late-appearing,  we  have  seen  that  the 
period  of  incubation  is  fairly  long  :  a  fortnight  or  three 
weeks  in  general,  and  sometimes  more.  Once  the 
first  clinical  signs  make  their  appearance  the  disease 
develops  through  two  or  three  well-defined  periods. 
The  first,  which  we  have  already  described  in  detail, 
is  characterised  by  a  permanent  contracture  of  one 
member,  or  of  two  symmetrical  members,  and  by 
painful  paroxysms  affecting  the  same  region.  This 
first  period  lasts,  on  an  average,  ten  to  twenty  days, 
sometimes  more,  as  in  our  own  observation. 

A  second  period  usually  follows  :  a  period  of  perman- 
ent, non-painful  muscular  rigidity.  The  contracture 
is  no  longer  accompanied  by  painful  paroxysms,  and 
the  permanent  rigidity  immobilises  the  patient  as  a 
complete  monoplegia  or  paraplegia  with  extreme  con- 
tracture would  do.  This  is  a  period  of  long  duration, 
and  if  we  examine,  for  example,  the  observations 
published  by  Demontmerbt,  which  deal  with  the  para- 
plegic form,  we  find  that  in  one  case  the  rigidity  per- 
sisted for  twenty-one  days  ;  in  another  case  for  forty 
days  ;  and  in  a  third  for  forty-nine.  Demontmerot  re- 
garded this  second  period,  with  its  peculiar  nature  and 
long  duration,  as  characteristic  of  the  paraplegic  form. 
However,  it  is  nothing  of  the  kind,  for  the  same  per- 
sistent stiffness  of  the  limb  attacked  by  the  tetanic 
infection  has  been  noted  in  the  monoplegic  forms. 
Courtellement,  who  was  the  first  to  publish  an  obsei-va- 
tion   of   tetanus  localised   in   one   limb,   had   already 


DEVELOPMENT  AND  PROGNOSIS         839 

insisted  upon  this  point ;  and  Pozzi  s  patient  still 
exhibited  this  second  period  of  non-painful  contracture 
after  the  lapse  of  more  than  forty  days.  More  than  a 
month  after  the  termination  of  the  first  period  of  de- 
velopment, Pozzi  wrote  that  his  patient's  left  lower  leg 
was  flexed  at  a  right  angle  to  the  thigh  by  the  powerful 
contracture  of  the  flexor  group  of  muscles,  whose  con- 
tracted tendons  could  be  felt  under  the  finger  in  the 
region  of  the  popliteal  space.  There  was  also  a  slight 
contracture  of  the  adductors.  The  extension  of  the 
leg  was  consequently  absolutely  impossible  ;  moreover, 
the  gastrocnemius  was  hard  and  rigid  as  a  woody  mass. 

This  period  is  often  followed  by  a  third  and  last 
period,  during  which  the  sequelae  of  the  preceding 
symptoms  establish  themselves,  develop,  or  disappear. 
There  may  be  a  musculo-tendinous  shortening ;  this  is 
especially  frequent  in  the  gastrocnemius  and  the 
tendo  Achillis,  as  in  our  own  observation  (XVI.).  In 
the  case  described  in  this  observation  there  was  a  very 
marked  retraction  of  the  tendo  Achillis,  which  prevented 
the  convalescent  patient  from  placing  his  heel  on  the 
ground  when  walking.  Trophic  disorders,  muscular 
or  cutaneous,  may  be  observed.  Muscular  atrophy  in 
particular  is  frequent ;  it  is  sometimes  slight  and  some- 
times severe.  Perforating  ulcer  of  the  sole  has  been 
observed. 

Lastly,  vaso-motor  disorders  may  appear.  These 
complications  can,  in  some  cases,  be  foreseen  and 
obviated  by  early  massage. 

It  will  readily  be  understood  that  these  complications 
involve  a  very  long  and  troublesome  convalescence, 
representing  the  fourth  period  of  the  disease. 

It  follows  that  the  total  duration  of  the  malady  in 
the    monoplegic,    paraplegic,    and    abdomino-thoracic 


840       THE  ABXORMAL  FORMS  OF  TETANUS 

forms  may  amount  to  one,  two,  or  three  months,  or 
even  longer.  In  addition  to  these  sub-acute  forms,  it 
will  be  remembered  that  there  are  forms  even  later- 
appearing,  more  attenuated,  and  longer  in  developing. 
Thus,  in  the  attenuated  forms,  we  have  seen  that  the 
development  is  extremely  slow,  owing  to  the  fact  that 
the  infection  is  attenuated  by  a  previous  preventive 
serotherapy. 

Prognosis. — The  localisation  of  the  tetanic  infection 
may  be  regarded  as  a  sign  of  the  benignity  of  the  dis- 
ease. It  must  not  be  supposed,  however,  that  recovery 
is  the  rule.  Partial  tetanus  is  a  serious  malady,  on 
account  of  the  complications  which  may  supervene, 
and  the  possible  secondary  generalisation  of  the  in- 
fection. 

The  gravity  of  atypical  tetanus  is  demonstrated  by 
the  observations  of  Routier.  This  author  recorded 
three  deaths  among  six  patients.  However,  in  the 
majority  of  cases,  partial  tetanus  of  the  members 
develops  in  the  direction  of  recovery,  if  we  except  the 
late-appearing  post-operative  forms,  whose  prognosis 
is  not  always  so  benign  as  that  of  the  retarded  forms 
which  occur  without  operation.  While  in  some  cases 
the  disease  assumes  an  acute  form,  of  the  ordinary  type, 
which  is  rapidly  fatal,  the  usual  progress  of  the  disease 
is  less  rapid.  The  onset  is  commonly  insidious,  the 
contracture  installing  itself  slowly  and  progressively, 
localising  itself  in  the  wounded  limb,  often  accompanied 
by  slight  trismus  and  stiffness  of  the  neck.  No 
paroxysmal  crises  are  observed,  or  only  late-appearing 
paroxysms  of  little  severity.  Of  the  contractures,  one 
of  the  most  constant  and  persistent  is  that  of  the 
abdominal  muscles. 

The    temperature    is   almost   normal.     Despite  the 


DEVELOPMENT  AND  PROGNOSIS         841 

sub-acute  form  of  the  disease,  and  its  insidious  advance, 
the  various  signs  which  we  have  just  recalled  may 
finally  become  aggravated,  terminating,  after  the  lapse 
of  several  weeks,  in  contracture  of  the  respirator}^ 
muscles  and  asphyxia. 

According  to  Bazy,  death  occurs  in  one  case  out  of 
two  or  three,  according  to  the  nature  of  the  cases.  But 
if  we  consider  only  the  observations  following  upon 
operative  intervention,  the  prognosis  is  even  more 
gloomy  ;  there  were  six  deaths  out  of  seven  cases 
successively  reported  by  Berard  and  Lumiere,  Querin, 
and  Leriche  and  Desplas. 

In  atypical  tetanus  it  seems  as  though  we  cannot 
seriously  base  our  prognosis  of  the  malady,  or  a  forecast 
of  its  development,  upon  symptomatology.  Although 
it  is  the  rule,  in  the  classical  form  of  tetanus,  to  regard 
the  prognosis  as  intimately  connected  with  the  length 
of  the  period  of  incubation  and  the  temperature,  this  is 
no  longer  the  case  in  the  abnormal  forms  of  tetanus. 

The  period  of  incubation,  as  we  have  many  times 
repeated,  is  extremely  variable.  It  may  be  long  or 
short,  but  the  prognosis  does  not  appear  to  be  affected 
thereby.  We  will  merely  remind  the  reader  that  the 
localised  forms  of  tetanus,  and  their  pathogenesis 
enables  us  readily  to  imderstand  this,  do  not  develop, 
as  may  happen  with  the  ordinary  forms,  within  a  few 
hours  of  the  wound  ;  a  fact  which  explains  why  the 
symptoms  never  appear  in  a  tumultuous  fashion, 
rapidly  followed  by  death.  But  the  indications 
furnished  by  the  duration  of  the  incubation  period  must 
not  be  regarded  as  absolute,  even  in  the  classical  form. 
Thus  Vautrin,  addressmg  the  Society  of  Medicine  of 
Nancy,  reported  cases  of  acute  tetanus  whose  onset 
was  extremely  tardy — the  periods  of  incubation  being 


843       THE  ABNORMAL  FORMS  OF  TETANUS 

twenty-two  and  fifty-four  days.  Comparatively  be- 
nign cases  with  a  brief  period  of  incubation  are, 
however,  very  exceptional. 

In  the  classical  form  of  tetanus  the  temperature  is, 
as  a  rule,  a  great  help  in  establishing  the  prognosis.  We 
know  that  pronounced  hyperthermia  and  extreme  fre- 
quency of  the  pulse  are  unfavourable  signs.  In  the 
abnormal  forms,  and  especially  in  partial  tetanus,  con- 
clusions drawn  from  an  examination  of  the  temperature 
are,  as  we  have  already  explained  at  some  length,  of 
little  value.  The  two  examples  reported  by  Routier 
are  a  striking  proof  of  this  assertion  ;  in  both  cases  the 
temperature  never  rose  above  102-2°  F.,  yet  death 
supervened  :  in  the  one  case  fourteen  days  after  the 
commencement  of  the  tetanic  symptoms,  and  in  the 
second  case  two  days  after  the  appearance  of  a  slight 
trismus,  and  painful  contractions  in  the  region  of  the 
elbow.  However,  it  sometimes  happens  that  the 
temperature  furnishes  no  indications,  even  in  the  purely 
classic  form  of  tetanus.  A  case  has  been  recorded  in 
which  the  temperature  never  exceeded  100*4°,  and  the 
pulse  90  to  96  per  minute,  but  which  terminated  in 
death,  despite  the  apparent  benignity  of  the  general 
symptoms.  The  acceleration  of  the  pulse  and  respiratory 
disorders  are  elements  of  gravity  even  in  the  partial 
and  atypical  forms. 

A  pulse  which  is  now  almost  normal,  now  very  rapid, 
and  a  jerky  respiration,  are  reasons  for  reserving  the 
prognosis. 

The  permanent  and  progressive  contracture  of  the 
abdominal  muscles  is,  as  we  have  stated,  an  almost 
constant  symptom  in  the  partial  forms  of  tetanus ; 
and  according  to  Berard  and  Lumi^re  it  should  be  re- 
garded as  of  great  importance  from  the  prognostic  point 


DEVELOPMENT  AND  PROGNOSIS  843 

of  view.  We  know  that  these  writers  regarded  this 
contracture  as  the  prelude  to  contracture  of  the 
respiratory  muscles  and  asphyxia. 

With  Routier,  we  do  not  believe  that  the  prognostic 
importance  which  Berard  and  Lumi^re  attribute  to  it 
should  be  attached  to  this  sign. 

Still,  one  should  always  look  out  for  this  contracture, 
as  when  associated  with  modifications  of  the  pulse  and 
the  temperature  it  may  give  us  reason  to  forecast  a 
fatal  termination.  We  repeat  once  more  that  as  this 
symptom  is  almost  the  rule  in  cases  of  partial  tetanus, 
whose  prognosis  is,  after  all,  comparatively  benign  as 
compared  with  that  of  the  normal  and  usually  observed 
form  of  the  disease,  its  presence  must  not  be  regarded 
as  a  prime  factor  in  the  establishment  of  a  positive 
prognosis. 

To  judge  of  the  probable  termination  of  a  case  of 
abnormal  tetanus,  we  must  also  consider  how  far  the 
deglutition  and  the  functions  of  the  larynx  are  affected. 
Again,  the  favourable  action  of  narcotics  upon  the 
cramps  should  be  regarded  as  a  favourable  sign. 

Finally,  if  we  are  to  believe  Dr  H.  Gordon  {The  Lancet, 
31st  December  1914),  the  prognosis  is  peculiarly  de- 
pendent upon  the  association  of  the  tetanic  bacillus 
with  other  virulent  bacteria,  and  especially  with  the 
anaerobic  bacilli  of  Welsch.  We  know,  too,  that 
tetanus  is  frequently  associated  with  gas  gangrene,  the 
bacilli  of  both  diseases  being  anaerobic. 

To  sum  up :  The  abnormal  forms  of  tetanus  owe 
their  benignity  to  their  localisation,  but  they  none  the 
less  constitute  a  serious  malady,  which  necessitates 
prompt  treatment ;  and  this  treatment,  as  6tienne 
observes,  must  combat  the  three  phases  of  the  disease  : 
infection,  intoxication,  and  cellular  reaction.    In  spite 


344      THE  ABNORMAL  FORMS  OF  TETAXUS 

of  everything,  therapeutics,  which  calls  for  combined 
treatment,  may  prove  inactive,  when  the  disease 
terminates  in  death  from  asphyxia,  due  to  the  tetanus 
of  the  respiratory  muscles,  although  the  muscular  con- 
tractures may  not  have  become  generalised.  Death  is 
not  always  the  result  of  the  contracture  of  the  respira- 
tory muscles,  and  Quincke  even  claims  that  in  many 
sufferers  from  tetanus  it  results,  on  the  contrary,  from 
the  complete  relaxation  of  the  respiratory  muscles — 
that  is,  from  their  paralysis. 

It  is  also  certainly  the  case  that  death  may  be  the 
consequence  of  a  secondary  generalisation  of  the 
tetanic  infection :  in  other  words,  of  a  septicaemia,  of  a 
tetanic  poisoning,  or  even  of  a  pulmonary  complication, 
such  as  the  pneumonia  of  deglutition. 


CHAPTER  IX 


TREATMENT 


We  propose  to  describe,  in  this  chapter,  the  various 
treatments  which  have  been  successively  recommended 
for  the  prevention  of  tetanus,  and  to  cope  with  the 
disease  when  developed. 

All  that  follows  may  be  applied  to  the  classic  forms 
as  well  as  to  the  atypical  varieties  of  the  tetanic  infec- 
tion. We  shall  give  a  brief  final  summary  only  of  such 
matters  as  have  especial  reference  to  the  abnormal 
forms,  and  shall  indicate  the  treatment  which  appears 
to  us  most  rational  and  efficacious. 

We  shall  consider  successively  : 

1.  The  prophylaxis  of  tetanus. 

2.  The  treatment  of  tetanus  properly  so  called. 
First  of  all  we  shall  emphasise  the  necessity  of  local 

treatment — that  is,  the  treatment  of  the  wound,  by 
which  the  infection  enters  the  system — and  shall  then 
proceed  to  deal  with  the  general  treatment,  which 
should  be  specific  and  symptomatic. 

•  Prophylaxis  of  Tetanus 

We  have  seen  that  Nicolaier's  bacillus  remains 
generally  localised  in  the  wound,  and  in  the  wound  the 
toxin  is  manufactured.  It  follows  from  this  that  the 
prophylaxis  of  tetanus,  which  must  be  local  and  general, 
is  based  upon  two  fundamental  principles  : 

(a)  The  complete  cleansing  of  the  wounds, 

(b)  Preventive  antitetanic  serotherapy. 

845 


846      THE  ABNORMAL  FORMS  OF  TETANUS 

Local  Treatment  of  the  Wounds 

It  is  absolutely  necessary  to  attend  to  every  suspicious 
wound ;  to  rid  it  of  the  tetanic  bacilli  which  may  have 
contaminated  it,  and  to  prevent  the  subsequent  growth 
of  the  germs. 

An  extensive  cleansing  of  wounds  should  always  be 
effected,  removing  the  particles  of  earth  and  the  shreds 
of  clothing  carried  into  the  wound  by  the  projectile ; 
lastly,  a  search  must  be  made  for  any  foreign  bodies. 
In  a  word,  the  wound  must  be  freed,  as  far  as  possible, 
from  bacillary  infection. 

Amputations. — Obviously  the  means  of  cleansing  a 
contaminated  wound  which  at  first  sight  appeared  most 
effectual  was  to  suppress  it  and  replace  it  by  a  new, 
aseptic  wound  :  hence  the  idea  of  amputating  limbs 
with  septic  wounds.  Thereby  the  introduction  of 
fresh  toxins  into  the  circulation  is  prevented.  Formerly, 
indeed,  ablation  and  excision  of  the  wound  was  recom- 
mended, and  even  the  amputation  of  the  extremities. 
It  has  fortunately  been  demonstrated  that  this  pro- 
cedure, which  was  indeed  unduly  radical,  was  ineffectual. 
Experience  has  shown  that  owing  to  the  invasion  of  the 
nervous  system  by  the  toxin,  mutilating  operations  can 
at  most  do  no  more  than  prevent  the  introduction  of 
further  toxins. 

In  our  experience  amputations  do  not  prevent  the 
outbreak  of  tetanus  ;  even  in  cases  of  serious  injury 
to  the  limbs  this  procedure,  in  our  opinion,  should  be 
rejected. 

The  Search  for  Projectiles. — When  these  are  not  too 
deeply  situated,  they  should  be  sought  for  as  promptly 
as  possible,  with  the  aid  of  the  X-rays  or  the  various 
apparatus  devised  for  the  purpose  of  discovering  foreign 


i 


TREATMENT  84? 

bodies  (Bergonie's  or  Fran9ois'  electro-vibrator,  etc.). 
Foreign  bodies  may  serve  as  the  nidus  for  Nicolaier's 
bacillus  and  the  other  anaerobic  germs  which  favour 
tetanic  toxi-infection.  By  removing  a  shell-splinter, 
or  a  bullet,  we  diminish  the  probabilities  of  suppura- 
tion, and  enable  the  cicatrisation  of  the  wound  to  pro- 
ceed more  rapidly.  Moreover,  this  procedure  enables 
us  to  rid  the  wound  of  tetaniferous  contaminations, 
and  to  avoid  a  secondary  intervention,  which  may  be- 
come, as  Berard  and  Lumiere  have  shown,  the  occasion 
of  renewed  virulence  on  the  part  of  the  tetanic  spores, 
and  the  origin  of  a  late  tetanus,  localised  or  otherwise. 

This  search  for  foreign  bodies  offers,  therefore,  a  two- 
fold advantage  from  the  point  of  view  of  prophylaxis. 

If  we  consider  the  cases  of  tetanus,  atypical  as  well  as 
classical,  which  have  occurred  during  the  present  war, 
we  find  that  asepsis  and  the  mere  cleansing  of  the 
wounds  is  not  sufficient  to  prevent  the  development  of 
tetanus. 

Antisepsis. — In  war  surgery  the  antiseptic  method 
must  be  employed.  Although  antisepsis  is  out  of 
fashion  nowadays,  surgeons  quickly  realised  the 
necessity  of  discovering  antiseptics  which  would  act 
upon  the  bacillus  of  tetanus. 

Chemical  Agents.  —  Tincture  of  Iodine.  —  In  vitro 
tincture  of  iodine  neutralises  the  tetanic  toxin,  but  it 
must  be  remembered  that  in  spite  of  the  constant  and 
systematic  employment  of  iodine  upon  wounds  received 
in  battle,  tetanus  has  appeared  with  comparative 
frequency. 

Oxygen.  Nicolaier's  bacillus  being  anaerobic,  the 
idea  arose  that  it  might  be  destroyed  by  bringing  it  into 
contact  with  oxygen.  For  this  purpose  oxygenated 
water  was  employed,  and  hyper-oxidised   substances 


848      THE  ABNORMAL  FORMS  OF  TETANUS 

which  readily  Hberate  oxygen.  Oxygen,  moreover, 
acts  not  only  on  the  bacilli,  but  also  on  the  toxins  which 
they  secrete. 

This  property  of  the  tetanic  germ,  of  developing  in 
the  absence  of  oxygen,  known  as  anserobiosis,  provides 
therapeutics  with  a  valuable  means  of  attacking  the 
tetanus  bacillus.  Numerous  preparations  possess  the 
property  of  liberating  oxygen  at  the  surface  of  a  wound  ; 
oxvsenated  water  may  be  used  in  this  wav,  or 
magnesium  peroxide. 

All  wounds  which  have  been  contaminated  by  the 
soil,  by  shreds  of  dirty  clothing,  or  by  a  foreign  body, 
are  suspect  from  the  point  of  view  of  tetanus.  Such 
wounds  must  therefore  be  cleansed  with  oxygenated 
water  or  powders  which  give  off  oxygen.  The  same 
with  old  wounds  which  have  given  rise  to  tetanic  in 
fection  :  no  good  result  can  be  obtained  save  by  acting 
upon  them  with  oxygen.  The  tetanic  bacillus  is  killed 
by  oxygen,  and  the  gas,  especially  iji  the  nascent 
state,  slowly  cleanses  the  wound,  destroying  toxins, 
detaching  shreds  of  fat,  clots  of  blood,  and  dead 
tissues,  without  ever  exercising  any  harmful  action 
(Dutertre). 

Certain  writers  have,  while  experimenting,  observed 
a  fact  of  great  interest  and  importance — namely,  that 
the  toxicity  of  various  toxins  is  destroyed  ]by  the  per- 
oxides. They  have  succeeded,  by  means  of  oxygenated 
water  and  peroxide  of  calcium,  in  annulling  the  toxicity 
of  a  large  number  of  toxins. 

The  same  result  may  be  obtained  by  means  of 
ammonium  persulphate.  This  is  a  powerful  oxidising 
agent,  which  also  possesses  appreciable  powers  of  dis- 
infection. Unlike  hydrogen  peroxide  and  calcium  per- 
oxide, it  may  be  employed  in  intravenous  injections. 


TREATMENT  849 

It  has  little  toxicity  ;  a  neutral  salt,  of  a  light  base, 
it  remains  neutral  while  yielding  its  oxygen. 

Oxygen  acts  not  only  upon  the  tetanus  bacillus,  but 
on  its  toxin  ;  hence  its  employment,  not  merely  as  a 
preventive,  but  also  as  a  curative  remedy.  Wounds  of 
a  suspect  nature,  and  wounds  infected  with  the  tetanic 
bacillus,  should  therefore  be  treated  with  oxygen. 

Calcium  Hypochloride. — According  to  certain  writers, 
chlorine  prevents  the  development  of  the  tetanic  bacilli 
and  the  production  of  toxins  in  the  wound. 

Despite  these  considerations,  the  various  antiseptics 
have  in  reality  hardly  any  effect  upon  the  tetanic 
spores,  whose  powers  of  resistance,  as  we  have  seen,  are 
considerable.  On  the  other  hand,  they  do  act  upon 
the  ordinary  microbes,  the  germs  of  suppuration,  whose 
association  with  the  tetanic  bacillus  is  necessary  to 
ensure  its  pathogenic  action. 

The  employment  of  desiccated  and  powdered  anti- 
tetanic  serum  has  also  been  recommended  in  the  case  of 
extensive  or  lacerated  wounds.  But  this  procedure  is 
far  from  sufficient  alone  as  a  protection  against  tetanus, 
unless  it  is  seconded  by  the  injection  of  the  serum.  In 
this  connection  Merieux  found  that  a  mixture  of  anti- 
tetanic  serum  and  sub-gallate  of  bismuth,  applied  to  a 
contaminated  wound  six  hours  after  contamination, 
prevents  the  development  of  tetanus  in  the  guinea-pig. 

Physical  Agents. — Hot  or  Cold  Air. — Clinicians  have 
conceived  the  idea  of  treating  wounds  suspected  of 
tetanic  infection  by  means  of  insufflations  of  air.  The 
following  treatment  has  been  recommended  :  no  sutures 
are  made  ;  on  the  contrary,  the  wound  is  fully  opened 
up  ;  lacerated,  bruised,  or  mortified  tissues  are  ablated 
as  promptly  as  possible  ;  and  the  large  wounds  thus 
opened  are  treated  by  means  of  insufflations  of  hot  air. 


850      THE  ABNORMAL  FORMS  OF  TETANUS 

This  procedure,  which  dries  the  wounds  and  stimulates 
the  production  of  fleshy  vegetation,  has  been  employed 
with  success  by  various  surgeons. 

Cold  air  gives  the  same  result,  but  its  employment  is 
slightly  painful. 

We  may  also  employ  an  intensive  current  of  air  in 
the  prophylaxis  of  tetanus.  It  will  be  readily  under- 
stood that  the  increased  supply  of  oxygen  carried  by  a 
powerful  current  of  air  into  all  the  recesses  of  a  wound 
prevents  the  development  of  the  anaerobic  bacilli  which 
cause  tetanus. 

These  various  procedures  act  principally  upon  the 
toxin,  and  it  would  be  a  matter  of  capital  importance 
could  we  destroy  this  tetanic  toxin  by  oxidation. 

As  a  matter  of  fact,  we  already  possess  a  means  of 
destroying  the  tetanus  bacillus  itself,  and  thus  of  pre- 
venting the  production  of  further  toxin.  The  ultra- 
violet rays  possess  this  bactericidal  property. 

Treatment  by  Light, — The  action  of  the  various  rays 
of  the  solar  spectrum,  and  of  full  sunlight,  has  long  been 
utilised  in  the  treatment  of  wounds  in  general.  We 
know  that  under  the  influence  of  the  ultra-violet  rays 
wounds  cleanse  themselves  and  cover  themselves  with 
fleshy  vegetation,  while  pain  is  alleviated. 

The  bactericidal  action  of  light  has  therefore  been 
employed  in  waging  war  upon  the  tetanus  bacillus. 
Moreover,  it  has  been  proved  experimentally  that  the 
toxin  of  tetanus  is  susceptible  to  the  action  of  luminous 
rays,  and  that  the  spores  are  extraordinarily  sensitive  to 
the  ultra-violet  rays.  Their  employment  should  accord- 
ingly constitute  one  of  the  best  methods  of  treatment. 

In  exposing  a  wound  to  light  our  principal  motive  is  to 
excite  an  inflammation,  an  augmentation  of  the  curative 
physiological  processes. 


TREATMENT  851 

This  inflammation  causes  a  hyperaemia  and  a  serous 
exudation,  of  arterial  origin,  as  well  as  an  abundant 
proliferation  of  the  tissues.  The  tetanus  bacilli  are 
therefore  attacked  in  two  ways  :  on  the  one  hand,  by  a 
greater  supply  of  oxygen  in  the  tissues,  caused  by  the 
inflammatory  reaction  provoked  by  the  light ;  and  on 
the  other  hand,  by  the  bactericidal  action  of  certain  rays 
of  the  spectrum. 

It  is  certain,  in  view  of  the  bactericidal  action  of  sun- 
light, as  well  as  its  curative  action  upon  wounds,  that 
our  wounded  patients,  especially  those  suspected  of 
tetanus,  ought  to  receive  as  much  sunlight  as  possible. 

Contagion. — From  the  prophylactic  point  of  view,  it 
must  be  remembered  that  wounds  which  upon  cultiva- 
tion yield  pure  cultures  of  tetanic  bacilli  are  not 
always  complicated  by  tetanus.  Analogous  facts  are 
well  known  to  obtain  in  the  case  of  other  infections — 
in  particular,  of  diphtheria  and  cerebro- spinal  menin- 
gitis ;  and  as  in  these  infections,  so  in  tetanus  there  are 
healthy  carriers  of  the  specific  bacillus,  who  may  be- 
come agents  of  contagion,  if  the  surgeon  neglects  the 
strictest  asepsis,  and  employs  the  same  instruments  in 
attending  a  number  of  patients. 

There  are  no  longer,  in  these  days,  ' '  epidemics  of 
tetanus,"  but  their  memory  proves  the  necessity  of 
subjecting  all  instruments  to  a  prolonged  sterilisation, 
preferably  by  means  of  the  autoclave,  in  order  that  the 
tetanic  spores  may  not  be  carried  from  one  wound  to 
another. 

It  must  be  remembered,  also,  that  some  years  ago 
several  cases  of  tetanus  were  reported  after  the  use  of 
gelatine  injections,  and  the  employment  of  catgut 
(cases  reported  in  France  and  America),  and  of  felt  in 
plaster-of- Paris  splints.     Great  care  must  therefore  be 


852        THE  ABNORMAL  FORMS  OF  TETANUS 

taken  to  sterilise  gelatine  and  catgut,  as  these  may 
contain  tetanic  spores. 

The  Action  of  Cold. —  Lastly,  cold  being  one  of  the 
factors  which  favours  the  appearance  of  tetanus,  care 
should  be  taken  that  the  wounded  man  is  not  chilled 
during  transportation,  and  that  he  is  warmed  directly 
he  enters  the  ambulance  or  hospital. 

Preventive  Serotherapy 

Despite  the  various  preventive  treatments  already 
discussed,  despite  the  most  rigorous  precautions  of 
asepsis  and  antisepsis,  it  must  be  admitted  that  it  is 
almost  impossible  to  eliminate  from  a  wound  the  tetanic 
germs  which  may  infect  it. 

To  protect  the  wounded  man  against  the  toxins 
secreted,  he  must  be  given  one  or  several  preventive 
injections  of  antitetanic  serum. 

Antitetanic  Serum. — History. — ^The  serum  of  animals 
immunised  by  the  injection  of  progressively  increasing 
doses  of  tetanic  toxin  possesses  properties  which  have 
been  utilised  in  the  prevention  and  the  attempted  cure 
of  tetanus.  Behring  and  Kitasato,  in  1890,  demon- 
strated the  antitoxic  powers  possessed  by  such  a  serum. 

In  1892  Vaillard  investigated  certain  points  relating 
to  the  serotherapy  of  tetanus.  The  blood  of  the  fowl 
does  not  neutralise  the  toxin,  but  it  becomes  antitoxic 
about  three  weeks  after  an  injection  of  filtered  culture 
into  the  peritoneum.  This  property  persists  for  eight 
months.  Vaillard  also  demonstrated  that  Nicolaier's 
bacillus  vegetates  and  elaborates  toxin  in  the  serum  of 
protected  animals  ;  that  it  multiplies  in  the  living 
tissues  of  an  immunised  animal ;  and  that  it  is  not 
attenuated  by  the  prolonged  action  of  the  lymph  of  a 


TREATMEyT  853 

protected  animal.  In  short,  the  serum  is  only  anti- 
toxic ;  it  is  not  bactericidal. 

In  1893  Roux  and  Vaillard  went  into  the  whole 
question  of  antitetanic  serum.  They  demonstrated, 
giving  technical  details,  that  the  serum  is  more  active  in 
vitro  than  when  injected  preventively.  The  guinea-pig, 
which  is  given  15,000  lethal  doses  of  toxin,  mingled  in 
vitro  ^vith  an  equivalent  quantity  of  serum,  is  able  to 
resist  the  toxin.  But  this  quantity  of  serum  would 
have  been  insufficient  to  protect  the  guinea-pig  against 
15,000  lethal  doses  of  the  toxin.  The  immunity  due  to 
the  injection  of  serum  is  acquired  immediately,  but  it 
lasts  only  for  a  few  days.  The  conclusions  of  Roux  and 
Vaillard  as  to  the  preventive  and  curative  properties  of 
the  serum  are  explicit.  Injected  simultaneously  with 
the  toxin,  or  within  a  few  hours,  it  transforms  a  general- 
ised and  mortal  tetanus  into  a  local  and  curable  tetanus ; 
injected  at  the  end  of  the  period  of  incubation,  or  after 
the  contractions  have  commenced,  it  is  absolutely  in- 
effectual. Since  then  the  antitetanic  serum  has  been 
employed  only  as  a  preventive.  Nocard  ardently 
reconmiends  its  employment ;  meanwhile  sufferers 
from  established  tetanus  are  still  given  the  serum,  and 
certain  cases  of  recovery  are  published,  which  are, 
however,  of  a  highly  debatable  nature. 

In  1898  Roux  and  Borrel  recommended  the  treatment 
of  established  tetanus  by  the  intra-cerebral  injection  of 
the  serum.  We  shall  refer  to  this  method  again  when 
discussing  the  specific  curative  treatment  of  tetanus. 

Preparation  oj  the  Serum. — ^Horses  are  inmiunised 
against  the  tetanic  toxin  by  injecting,  in  the  first  place, 
doses  of  the  toxin  attenuated  by  the  admixture  of  a 
solution  of  iodo-iodide.  These  injections  are  repeated 
every  three  or  four  days.    About  the  twenty-fifth  day. 


854       THE  ABNORMAL   FORMS  OF  TETANUS 

the  serum  already  exhibits  a  certain  antitoxic  power, 
which  is  then  greatly  reinforced  by  subcutaneous 
injections  of  pure  toxin  (10,  15,  20  c.c,  etc.,  every 
two  or  three  days).  At  the  end  of  six  weeks  about 
50,  100,   150,  or  even  350   c.c.  are  injected  into  the 

veins. 

The  horse  supports  these  enormous  doses  of  toxin — 
two  drops  of  which  would  suffice  to  kill  a  non-immunised 
horse — without  injurious  effects. 

Ten  days  after  the  last  injection  the  serum  is  collected 
by  venesection.  To  maintain  the  immunisation,  large 
doses  of  toxin  are  again  injected  at  intervals  of  a  few 
days. 

The  antitetanic  power  of  the  serum  survives  for  a 
very  long  time — a  year,  and  even  more  ;  it  is,  however, 
preferable  to  employ  none  but  recent  serum. 

The  serum  may  be  preserved  in  the  dry  state.  When 
required  for  use  it  suffices  to  dissolve  the  dry  serum  in 
six  volumes  of  sterilised  saline  water,  but  it  is  better  to 
use  the  natural  antitetanic  serum. 

To  avoid  the  slight  toxic  symptoms  which  may 
accompany  the  injection  of  any  serum,  the  serum  may 
be  warmed  for  twenty  to  thirty  minutes  to  a  tempera- 
ture of  138°  F.     It  is  then  less  irritant. 

Properties  of  Antitetanic  Serum. — Antitoxic  Powers. — 
If  an  appropriate  mixture  in  vitro  of  antitetanic  serum 
and  a  mortal  dose  of  toxin  be  injected  into  an  animal, 
no  tetanic  symptoms  develop,  and  the  animal  survives 
the  experiment.  Roux  and  Vaillard  were  able  to 
obtain  a  serum  which,  as  we  have  already  remarked, 
neutralises  100  mortal  doses  of  toxin  for  a  guinea-pig 
in  doses  of  1  in  100,000  c.c. 

This  antitoxic  power  being  proved,  the  above  writers 
established    under    what    conditions,    and    in    what 


TREATMENT  855 

quantities,  it  could  be  utilised  to  prevent  and  even  to 
cure  tetanus. 

Preventive  Power. — 1.  Against  the  Tetanus  Toxin. — 
An  animal  is  given  a  subcutaneous  dose  of  antitetanic 
serum  ;  then,  forty  to  sixty  minutes  later,  a  mortal  dose 
of  tetanus  toxin.  As  we  have  seen,  it  exhibits  no 
tetanic  symptoms,  and  ,sui*vives. 

We  know,  moreover,  having  dwelt  upon  the  fact  when 
considering  the  pathogenesis  of  atypical  tetanus,  that  if 
the  serum  and  the  toxin  are  injected  simultaneously 
at  different  points,  the  two  substances  are  diffused 
through  the  tissues  with  unequal  rapidity  ;  the  toxin 
outstrips  the  serum,  and  the  small  quantity  which  then 
escapes  the  action  of  the  antitoxin  suffices  to  provoke 
those  slight,  limited  forms  of  tetanus,  which  are  nearly 
always  curable. 

Finally,  if  the  serum  is  injected  after  the  toxin,  but 
before  the  onset  of  tetanic  symptoms,  the  tetanus  is 
always  local.  *The  later  the  injection  of  the  serum,  the 
larger  must  the  dose  be,  in  order  to  prevent  the  general- 
isation of  the  infection,  and  to  avert  a  fatal  result. 

2.  Against  the  Tetanic  Infection. — Against  experi- 
mental tetanic  infection  the  preventive  power  of  the 
serum  has  greater  scope  for  action,  since  there  is  always 
a  certain  interval  between  the  moment  of  inoculation 
and  the  moment  when  the  toxin  enters  the  circulation. 
On  the  other  hand,  the  poisoning  is  continuous,  the 
bacillus  continuing  to  secrete  its  toxin  as  long  as  it 
continues  to  live. 

The  injection  of  the  serum  before  infection  or  at  the 
moment  of  infection  indubitably  and  completely  con- 
fers protection  upon  animals. 

if  the  serum  is  injected  intravenously  after  infection, 
protection  is  assured  on  condition   that  the  serum  is 


856       THE  ABXORMAL  FOmiS  OF  TETANUS 

injected  within  forty-eight  hours  of  the  tetanigenous 
inoculation,  and  is  employed  in  sufficient  quantity.  If 
the  serum  is  given  by  intramuscular  injection  its  pre- 
ventive action  is  doubtful,  by  reason  of  the  slower 
absorption. 

The  immunity  conferred  by  the  serum  is  only  tem- 
porary. After  its  elimination  from  the  system,  about 
the  twelfth  or  fifteenth  day,  the  tetanic  spores  im- 
mobilised by  the  phagocytes,  being  no  longer  affected 
by  the  senim,  are  able  to  develop,  and  to  pour  the  toxin 
into  the  circulation  at  a  time  when  there  is  no  longer 
any  antitoxin  to  arrest  or  to  hinder  its  action. 

The  proof  of  these  experimental  data  was  established 
by  Nocard,  who  experimented  upon  the  horse  and  the 
larger  domestic  animals.  Certain  accidents  from  which 
these  animals  frequently  suffer  (wounds  from  nails  in 
the  road,  or  wounds  inflicted  by  the  farrier,  etc.),  and 
operations,  such  as  castration,  the  amputation  of  the 
tail,  and  the  reduction  of  hernia,  are  often  enough 
followed  by  tetanus.  Out  of  more  than  2500  animals 
given  a  preventive  injection  immediately  after  opera- 
tion, not  one  contracted  tetanus.  Out  of  6000  others, 
treated  one  to  four  days  after  the  infliction  of  wounds 
contaminated  by  dung,  soil,  earth,  nails  lying  in  the 
road,  etc.,  only  one  contracted  tetanus.  At  the  same 
time  there  were  315  cases  of  tetanus  among  animals 
which  received  no  preventive  injection. 

Combining  the  statistics  collected  by  Xocard,  Labat, 
and  Vallee,  among  16,917  animals  which  were  given 
preventive  injections,  Vaillard  discovered  only  one  case 
of  tetanus.     No  more  conclusive  statistics  could  exist. 

We  shall  presently  see  that  the  preventive  power  of 
the  serum  when  administered  to  human  patients  is 
indisputable,  and  that  the  cases  of  tetanus  in  wounded 


TREATMENT  857 

men  who  have  been  treated  with  serum  have  occurred 
in  instances  where  the  serum  was  injected  too  long  after 
the  infliction  of  the  wound  by  which  the  infection 
entered,  and  in  which  the  bacillus  continued  to  grow 
and  secrete  its  toxin,  as  the  injections  were  not  repeated 
after  the  elimination  of  the  serum. 

Now  that  we  have  learned  the  fundamental  properties 
of  the  antitetanic  serum,  and  before  indicating  the 
principles  of  preventive  serotherapy,  we  will  briefly 
insist  upon  the  innocuousness  of  the  treatment,  and  its 
efficacy. 

It  would  seem  needless,  after  the  numerous  examples 
provided  by  the  present  war,  to  devote  any  space  to 
this  subject.  We  have  been  induced  to  do  so,  however, 
by  the  comparatively  recent  discussion  of  serotherapy 
and  its  dangers,  and  in  particular  by  the  report  read 
by  M.  Netter  before  the  Academy  of  Medicine,  during 
its  session  of  the  2nd  of  May  last.  This  writer,  how- 
ever, declared  that  serious  symptoms  resulting  from 
a  first  injection  (the  serum  sickness  which  we  shall 
presently  describe),  or  from  reinjections  (anaphylactic 
accidents)  are  very  rare  ;  above  all,  if  the  injection  is 
made  in  the  subcutaneous  cellular  tissue.  Moreover, 
it  must  be  admitted  that  the  fear  of  accidents  ought 
never  to  deter  us  from  having  recourse  to  serotherapy. 

Certain  physicians  and  surgeons  who  have  denied  the 
prophylactic  value  of  the  serum,  and  who  have  further 
accused  it  of  being  the  cause  of  distressing  symptoms, 
have  shaken  the  confidence  of  many  practitioners,  and 
it  is  in  order  to  refute  the  arguments  invoked  against 
the  use  of  antitetanic  serum  that  we  feel  obliged  to 
emphasise  the  innocuousness  and  the  efficacy  of  pre- 
ventive serotherapy.  It  must  unhappily  be  admitted 
that  many  of  the  deaths  from  tetanus  recorded  at  the 


858      THE  ABNORMAL  FORMS  OF  TETANUS 

beginning  of  the  war  were  due  precisely  to  the  erroneous 
ideas  which  had  been  expressed  concerning  the  dangers 
of  preventive  serotherapy. 

Innocuous ness  of  the  Antitetanic  Serum. — Some  have 
attributed  to  antitetanic  serum  a  series  of  symptoms 
which  are  common  to  the  various  therapeutic  serums. 
These  are  not  due  to  any  peculiar  property  of  the  anti- 
tetanic serum  ;  and  since  the  investigations  of  von 
Pirquet  and  Charles  Richet  these  complications  have 
been  thoroughly  understood.  Discussing  the  accidents 
consequent  upon  serotherapy,  we  shall  distinguish  be- 
tween those  which  follow  a  first  injection  and  those 
which  occur  after  reinjection.  We  shall  describe, 
therefore,  on  the  one  hand,  the  serum  sickness  ;  and  on 
the  other  hand,  the  anaphylactic  accidents. 

Accidents  following  a  First  Injection. — Between  the 
eighth  and  the  fifteenth  day  after  a  subcutaneous  in- 
jection of  antitetanic  serum,  and  occasionally  later,  but 
seldom  sooner,  the  patient  may  exhibit  three  symptoms, 
associated  or  singly  :  an  eruption,  pains,  and  a  slight 
rise  of  temperature. 

The  eruption,  localised  in  the  region  of  the  face, 
presently  becomes  generalised,  and  may  assume  one  of 
several  different  aspects.  The  urticarial,  pruriginous 
forms  are  most  frequent ;  these  consist  of  a  diffused 
eruption  of  small  or  of  moderate  dimensions,  or  large 
red  patches,  which  undergo  progressive  extension. 
Their  aspect  sometimes  recalls  the  eruption  of  measles, 
or  an  erythema  like  that  of  scarlet  fever.  We  have 
sometimes  had  patients  sent  to  us  as  contagious  cases, 
who  were  merely  suffering  from  a  serum  eruption,  as  was 
demonstrated  by  the  history  and  the  development  of 
the  malady.  In  the  course  of  the  scarlatiniform  serum 
erythema  it  should  be  remembered  that  desquamation 


TREATMENT  859 

may  occur  in  large  patches,  but  in  general  it  takes  place 
earlier  than  in  true  scarlatina,  and  is  not  accompanied 
by  angina. 

Very  frequently,  too,  the  serum  eruption  is  poly- 
morphic ;  it  then  consists  of  a  morbillo-scarlatiniform 
erythema  with  predominance  of  urticarial  elements. 

The  pains  are  felt  in  the  joints,  but  no  local  swelling 
is  observed.  Usually  they  recall  simple  arthralgia 
without  tumefaction,  and  more  rarely  simple  neuralgia, 
or  myalgia. 

The  elevation  of  temperature  is  slight ;  the  ther- 
mometer rarely  rises  above  100-5°  F.  Sometimes, 
however,  as  we  shall  see,  it  does  exceed  this  figure. 

This  serum  sickness,  which  is  slight  and  without 
gravity,  rarely  continues  for  longer  than  four  days. 
Its  frequency  varies  greatly,  according  to  the  mode  of 
preparing  the  serum  ;  it  is  less  common  in  France 
(where  it  occurs  in  13  to  14  per  cent,  of  cases)  than  in 
Germany,  which  is  due  to  the  fact  that  the  French 
serum  is  heated  to  56°  C.  Even  when  the  mode  of 
preparation  is  identical,  the  syndrome  develops  more 
readily  when  the  serum  of  certain  horses  is  employed. 
It  is  not  possible  to  explain  precisely  why  this  should 
be  so. 

The  serum  reaction  is  occasionally  more  marked. 
The  temperature  rises  to  104°  F.,  which,  in  the 
presence  of  a  morbilliform  erythema,  and,  above  all,  of 
a  scarlatiniform  erythema,  does  not  facilitate  diagnosis. 

In  such  cases  delirium  may  be  observed,  and  agita- 
tion, or  even  meningeal  reactions,  with  headache,  stiff- 
ness of  the  nape,  and  Kernig's  sign.  The  kidneys  may 
in  turn  be  affected,  a  condition  which  will  be  revealed, 
upon  testing  the  urine,  by  the  presence  of  albumin,  and 
clinically,  sometimes,  by  oedema. 


860       THE  ABNORMAL  FORMS  OF  TETANUS 

In  a  few  cases  the  lymphatic  glands  are  hypertropmed. 
This  veritable  serum  sickness  does  not  usually  last  more 
than  a  few  days,  but  it  leaves  behind  it  a  prolonged 
adynamia.  Regnier  has  even  published  an  observa- 
tion of  a  case  in  which,  a  week  after  the  injection  of  the 
antitetanic  serum,  pericarditis  supervened,  the  sequelae 
of  which  persisted  for  a  year. 

A  few  fatal  cases  have  been  reported.  Thus,  Riche 
reported  the  case  of  a  child,  observed  by  Rilhac,  which 
was  rapidly  fatal,  with  hypothermia  and  Cheyne- 
Stokes  breathing.  The  subject  had  received  a  preven- 
tive injection  of  10  c.c.  of  antitetanic  serum. 

Other  writers  have  been  so  far  mistaken  as  to  inquire 
whether  the  preventive  injection  might  not  in  certain 
cases  have  determined  the  appearance  of  the  clinical 
signs  of  tetanus.  In  the  majority  of  such  cases  there 
were  meningeal  reaction^,  with  pseudo-tetanic  con- 
tractures: temporo-maxillary  arthralgia  producing 
trismus,  or  arthralgia  of  the  vertebral  column  deter- 
mining a  stiffness  of  the  trunk.  Lastly,  if  we  very 
carefully  analyse  the  majority  of  the  fatal  cases 
observed  subsequently  to  serum  injections,  we  find 
that  in  certain  instances  death  was  attributable  not 
to  the  serum,  but  to  acute  septicaemia  due  to  a  septic 
injection.  In  certain  cases,  moreover,  an  alteration 
or  accidental  contamination  of  the  serum  may  be 
incriminated. 

The  symptoms  which  follow  a  first  injection  of  anti- 
tetanic serum  are  explained  by  the  well-known  toxicity 
which  any  animal  serum  presents  for  an  animal  of 
another  species  when  injected  into  the  latter.  We 
know  that  a  heterogeneous  non-antitoxic  serum  of  any 
kind  causes  similar  symptoms. 

Marfan,  however,  would  attribute  a  certain  action  to 


TREATMENT  861 

the  antitoxin.  According  to  him  phenomena  of  pre- 
cipitation occm*  in  vivo  analogous  to  those  which  occur 
in  vitro  when  a  toxin  is  brought  into  contact  with  the 
corresponding  antitoxin.  The  precipitants  formed  in 
the  blood  after  the  injection  of  antitetanic  serum  into 
a  wounded  man  already  intoxicated  by  the  tetanic 
toxin  give  rise  to  capillary  embolisms  which  might  be 
the  anatomical  substratum  of  the  symptoms. 

This  theory  is  not  enough  to  explain  the  symptoms 
which  occur  in  the  case  of  numbers  of  wounded  men 
who  are  not  already  infected  by  tetanus. 

Symptoms  due  to  the  Reinjection  of  Serum. — ^These 
may  be  early  or  late-appearing. 

Symptoms  appearing  some  time  after  Reinjeotion.— 
These  may  be  summarised  as  eruptions,  paius  anu 
fever  ;  they  are  of  brief  duration,  and  their  prognosis 
is  benign.  They  recall  the  symptoms  which  we  have 
already  mentioned  as  occurring  after  a  first  injection  of 
serum,  and  differ  from  these  only  by  a  greater  fre- 
quency and  a  shorter  period  of  incubation.  Thus  in 
France  they  are  obsei*ved  ui  50  per  cent,  of  cases, 
instead  of  13  or  14  per  cent.,  and  they  appear  two  to 
five  days  after  reinjection,  instead  of  eight  to  fifteen 
days  after  the  first  injection,  as  we  have  already 
seen. 

Their  pathogenesis  is  probably  the  same. 

Symptoms  which  appear  soon  after  Reinjection. — ^The 
immediate  symptoms,  on  the  other  hand,  are  peculiar 
to  reinjection,  and  present  special  characteristics. 
They  may  be  local  or  general. 

The  local  phenomena  often  follow  a  benign  develop- 
ment. 

At  the  point  of  reinjection,  and  almost  inmiediately 
after  the  serum  is  administered,  a  more  or  less  marked 


862        THE  ABNORMAL  FORMS  OF  TETANUS 

redness  makes  its  appearance,  or  a  painful  oedema,  or 
urticaria.  These  abnormal  phenomena  are  usually  of 
brief  duration,  disappearing  in  a  few  hours,  or  at  all 
events  in  a  day  or  two. 

Nevertheless,  a  local  gangrene  may  be  observed  at 
the  point  of  reinjection,  accompanied  by  serious 
general  indications.  Eight  such  cases,  followed  by 
death,  have  been  reported  in  the  course  of  an  incalcul- 
able number  of  reinjections  of  serum.  However,  all 
these  cases  occurred  in  the  course  of  anti-diphtheritic 
serotherapy,  and  death  appears  to  have  been  due  to  the 
coexistence  of  a  dangerous  state  of  infection. 

General  Symptoms. — The  general  immediate  symptoms 
consist  of  a  rapid  collapse  with  diminution  of  arterial 
pressure.  This  collapse  varies  in  duration.  But  in 
infected  and  debilitated  subjects  these  disorders,  which 
are  but  slightly  marked  at  the  outset,  become  aggra- 
vated instead  of  attenuated.  Two  cases  of  sudden 
death  have  been  reported,  one  after  a  reinjection  of 
anti-plague  serum,  and  one  after  the  administration  of 
anti-diphtheritic  serum.  The  history  of  these  very 
exceptional  accidents  is  elucidated  by  that  of  experi- 
mental reinjection  (Richet  and  Portier,  1902). 

We  must  conclude,  from  the  experimental  data,  that 
the  subcutaneous  reinjection  of  serum  is  less  dangerous 
than  intravenous  or  intracerebral  reinjection,  which 
may  cause  death  within  a  few  minutes. 

It  must  also  be  remembered  that  the  symptom- 
atology of  experimental  anaphylaxis  does  not  make  its 
appearance  unless  injection  and  reinjection  are  separ- 
ated by  an  interval  of  a  fortnight.  It  varies,  moreover, 
in  different  animal  species. 

In  man  the  frequency  of  anaphylactic  accidents  has 
been    greatly    exaggerated.     We    shall    refer    to    two 


TREATMENT  863 

definite  cases,  when  discussing  the  curative  treatment 
of  tetanus. 

In  a  generalised  and  complicated  infection  it  is 
difficult  to  distinguish  the  symptoms  which  are  depend- 
ent on  the  causal  malady  from  those  due  to  the  reaction 
of  the  system  under  the  influence  of  serotherapy  or  the 
therapeutic  agents  employed.  Only  the  immediate  or 
late-appearing  symptoms  which  we  mentioned  as 
occurring  in  man  recall  the  anaphylactic  accidents  of 
animals  ;  the  local  gangrene  which  may  be  observed  at 
the  point  of  reinjection  is  analogous  to  the  gangrenous 
phenomenon  of  Arthur,  and  the  cardiac  collapse  to  the 
anaphylactic  shock.  However,  serious  symptoms  are 
exceptional,  and  some  of  them  may  be  avoided  by 
taking  a  few  precautions. 

In  this  connection  Marfan  has  recently  laid  stress 
upon  the  abuse  of  injections  of  heterogeneous  serums  ; 
the  abuse  of  serums  whose  efficacy  is  doubtful,  such  as 
the  anti-streptococcic  serum,  which  certain  physicians 
recommend  in  erysipelas  ;  the  abuse  of  specific  serums 
injected  for  a  non-specific  object — for  example,  the  in- 
jection of  anti-diphtheritic  serum,  or  ordinary  horse 
serum,  in  severe  hsemorrhage,  diseases  of  the  blood, 
ocular  infections,  etc.  It  must  not  be  forgotten  that 
the  extension  of  serotherapy  involves  the  risk,  some- 
times without  the  excuse  of  absolute  necessity,  of 
placing  a  large  number  of  patients  in  a  condition  of 
hyper- sensibility  in  respect  of  serum  reinjection  which 
may  be  absolutely  indispensable  should  they  ever 
happen  to  be  wounded,  or  to  contract  diphtheria,  or 
cerebro- spinal  meningitis,  several  months  or  years  after 
the  first  injection  of  serum. 

As  it  is  the  heterogeneous  albumin  which  enters  into 
action  rather  than  the  antitoxin,  anaphylaxis  occurs 


864       THE  ABNORMAL  FORMS  OF  TETANUS 

indifferently  when  the  injections,  divided  by  a  longer 
or  shorter  lapse  of  time,  have  been  made  with  the  same 
serums,  or  with  serums  differing  in  their  antitoxins. 
Thus,  a  first  injection  of  anti-diphtheritic  serum  or  anti- 
meningococcic serum  may  become,  on  the  occasion  of 
an  antitetanic  reinjection,  the  origin  of  anaphylaxis. 

Among  the  measures  to  be  taken  to  avoid  accidents, 
we  must  mention  the  preventive  administration  of 
chloride  of  calcium,  in  doses  of  1  gramme  per  diem, 
and  of  adrenaline  in  doses  of  ten  to  fifteen  drops  of  a 
1  in  1000  solution.  The  adrenaline,  whose  hypertensive 
action  is  well  known,  will  prevent  or  oppose  the  sudden 
fall  of  arterial  pressure  which  is  observed  at  the  moment 
of  the  anaphylactic  shock.  These  therapeutic  agents, 
which  are  specially  to  be  recommended  on  the  occasion 
of  reinjection  in  the  curative  serotherapy  of  tetanus, 
should  be  employed  in  preventive  serotherapy  when  a 
few  slight  accidents  have  been  observed  at  the  time  of 
the  first  injection,  when  the  patient  is  infected  and  en- 
feebled, or  when  he  exhibits  a  pathological  taint.  In 
a  tuberculous  patient,  or  one  predisposed  to  urticaria, 
asthma,  or  hay  fever,  they  should  always  be  employed. 

In  all  cases  of  wounded  men  who  have  previously, 
for  any  reason,  received  one  or  more  injections  of  serum 
or  serums,  and  in  those  cases  especially  in  which  anaphy- 
lactic accidents  appear  to  be  more  readily  produced, 
the  anti-anaphylactic  method  of  Besredka  should  be 
employed.  This  is  based  on  the  employment  of  small 
doses.  If  no  marked  anaphylactic  symptoms  are 
observed,  it  is  possible,  after  a  certain  lapse  of  time,  to 
inject  large  doses  oi  serum  without  serious  accidents. 
Thus,  if  in  the  first  place  we  inject,  subcutaneously, 
0-5  CO.  to  1  c.c.  of  serum,  we  may,  three  or  four  hours 
later,  inject  the  total  necessary  dose.     This  will  be 


TREATMENT  865 

given  slowly,  in  order  that  the  injection  may  be  sus- 
pended upon  the  slightest  threat  of  accidents. 

Certain  writers  have  recommended  the  addition  to 
the  serum  of  such  substances  as  hydrochloric  acid, 
iodine,  sulphate  of  magnesium,  formol,  or  chloroform, 
with  the  object  of  suppressing  the  effects  of  the  ana- 
phylotoxin.  This  method  should  be  abandoned,  for  it 
has  not  given  satisfactory  results. 

It  follows,  from  these  facts,  that  in  practice  these 
anti-anaphylactic  precautions  must  be  taken  whenever 
it  is  possible  to  do  so.  It  is  obvious  that  in  a  dressing- 
station  or  field  hospital,  where  there  are  great  numbers 
of  seriously  wounded  men,  it  is  often  impossible  to  dis- 
cover whether  the  patient  has  previously  received  an 
injection  of  any  kind  of  serum,  or  to  wait  three  hours 
or  longer  between  the  injection  of  the  small  anti- 
anaphylactic  dose  and  that  of  the  massive  dose  which  is 
required.  In  such  cases  there  is  no  room  for  hesitation, 
it  being  a  matter  of  urgency  to  inject  all  the  wounded 
without  distinction.  Moreover,  we  are  a  hundred  times 
more  likely  to  expose  the  wounded  man  to  the  risk  of 
tetanus  by  refraining  from  administering  the  preven- 
tive antitetanic  injection  than  to  produce  serious  ana- 
phylactic symptoms  by  a  serum  reinjection  which  takes 
no  account  of  his  pathological  past. 

We  have  no  hesitation  in  repeating  that  the  fear  of 
accidents  following  upon  a  seric  reinjection,  whether 
it  has  reference  to  tetanus,  or  cerebro-spinal  meningitis, 
or  diphtheria,  has  caused  many  more  deaths  than 
anaphylaxis  itself. 

The  Efficacy  of  Preventive  Serotherapy. — According  to 
the  opponents  of  the  preventive  serotherapeutic  treat- 
ment, the  serum  is  not  only  dangerous,  but  has  no  effect 
upon  the  final  development  oi  the  disease.     They  base 


866      THE  ABNORMAL  FORMS  OP  TETANUS 

their  erroneous  conceptions  on  the  development  of 
a  few  cases  of  tetanus,  and  their  gravity,  despite  the 
employment  of  serotherapy. 

Regnier,  in  this  connection,  reminds  us  that  41 
cases  of  tetanus  developed  in  spite  of  preventive  in- 
jections, and  that  of  18  cases  observed  in  France  13 
were  fatal.  This  figure,  41,  taken  from  the  statistics 
published  by  Vaillard  in  1906,  is  by  no  means  exag- 
gerated, and  Chattet,  in  1909,  increased  it  to  51.  If  we 
compare  this  figure  with  the  numerous  observations  of 
cases  which  have  developed  in  the  absence  of  sero- 
therapy, and  if  we  subtract  from  it  19  cases  which, 
according  to  a  conscientious  analysis  undertaken  by 
Chattet,  should  be  regarded  as  doubtful  or  wrongly 
diagnosed,  we  see  that  such  statistics  are  of  little  value 
as  an  argument  against  the  genuinely  efficacious  char- 
acter of  preventive  serotherapy,  especially  as  we  know 
that  in  some  of  the  32  cases  on  which  we  may  rely  the 
physician  contented  himself  with  powdering  the  woimd 
with  dried  serum,  a  method  which  is  recognised  by  all 
as  blind  and  insufficient. 

We  have  already  referred  to  the  eloquent  statistics 
of  the  veterinary  practitioners,  and  of  Nocard  in 
particular,  concerning  the  importance  of  preventive 
serotherapy,  and  the  results  obtained  by  its  employ- 
ment. In  human  medicine  also  the  majority  of 
surgeons  and  physicians  recognise  that  tetanus  declares 
itself  only  when  the  preventive  injection  has  been 
omitted.  Moreover,  the  colonial  wars  have  proved  the 
value  of  preventive  serotherapy,  to  say  nothing  of  the 
recent  statistics  of  Sieur  and  Bazy. 

Sieur  published  in  January,  1915,  the  statistics 
of  tetanus  in  the  army.  He  had  observed  7  cases 
among  17,507  wounded,  or  -039  per  cent.,  and  this  low 


TREATMENT  867 

proportion  was  due  to  the  systematic  administration  oi 
preventive  injections  to  all  the  wounded. 

Bazy,  among  10,986  wounded  men  in  hospitals  in  the 
entrenched  camp  of  Paris,  reported  only  129  cases,  and 
in  those  sections  of  the  army  in  which  a  preventive  in- 
jection was  given  to  every  man  wounded,  the  proportion 
of  tetanic  patients  was  -48  per  cent.,  while  in  the  other 
sections  it  was  1*299  per  cent.,  or  three  times  as  high. 

Out  of  200  wounded  men  100,  without  exception, 
and  without  selection,  were  given  preventive  injec- 
tions ;  only  one  contracted  tetanus.  In  his  case  the 
prophylactic  injection  was  given  too  late  ;  in  reality 
the  morbidity,  for  this  series,  was  0.  A  hundred 
soldiers  subjected  to  the  same  conditions,  but  given  no 
preventive  injections,  yielded  18  cases  of  tetanus,  or 
nearly  one  case  in  five. 

Fifty  other  wounded  men,  comprising  10  with 
wounds  in  a  state  of  suppuration,  produced  by  shell- 
splinters,  and  40  with  wounds  produced  by  rifle-bullets, 
received  each  one  a  preventive  injection  ;  not  one  of 
them  had  tetanus.  This  injection  was  given  within 
five  days  of  the  infliction  of  the  wound. 

These  figures  appear  to  us  the  best  demonstration  of 
the  efficacy  of  preventive  serotherapy,  and  it  would  be 
still  more  efficacious  if,  as  we  shall  now  explain, 
physicians  did  not  content  themselves  with  a  single  in- 
jection, and  if  the  requirements  of  serotherapy  were 
more  carefully  fulfilled. 

Rules  of  Preventive  Serotherapy. — (a)  As  a  general 
rule,  every  wound  received  in  war  should  be  regarded 
as  contaminated  by  tetanic  spores ;  just  as  every 
wound,  large  or  small,  contaminated  by  the  soil  or 
produced  by  an  infected  object,  calls  for  a  preventive 
sero therapeutic  injection. 


868       THE  ABNORMAL  FORMS  OF  TETANUS 

While  those  wounds  which  are  accompanied  by  exten- 
sive laceration  or  destruction  of  the  tissues,  together 
with  compHcated  fractures,  are  most  Uable  to  be  com- 
pUcated  by  tetanus,  we  must  not  neglect  seton-like 
wounds,  or  slight  and  superficial  wounds,  which  are 
all  the  more  likely  to  be  the  starting-point  of  tetanic 
infection  because  many  surgeons  regard  them  as  un- 
important and  devoid  of  gravity. 

We  will  even  go  so  far  as  to  say  that  in  the  case  of 
every  wound  received  in  war  time,  whatever  its  situa- 
tion, its  extent,  and  the  nature  of  the  projectile  causing 
it,  the  physician  should  have  recourse  to  an  injection  of 
antitetanic  serum  as  a  prophylactic  measure. 

Similarly  all  accidental  wounds,  frost-bites  or  chil- 
blains which  have  reached  the  ulcerative  stage,  or  have 
mortified,  and  all  burns,  should  be  followed  by  preven- 
tive antitetanic  serotherapy. 

(&)  The  injection  should  be  given  as  soon  as  possiblcy 
before  the  toxin  has  had  time  to  diffuse  itself  through 
the  system  ;  which  it  does,  by  the  way,  very  rapidly. 
In  many  cases  of  tetanus  which  have  developed  in  spite 
of  a  preventive  injection,  it  is  found  that  the  injection 
was  administered  one,  two,  or  three  days  after  the 
traumatism. 

(c)  Contrary  to  the  belief  current  among  medical 
writers  in  the  early  days  of  serotherapy,  a  single  injec- 
tion is  not  sufficient.  We  know,  in  fact,  that  the  period 
of  immunity  conferred  does  not  exceed  eight  days,  and 
that  the  tetanic  bacillus  may  persist  much  longer  than 
this.  Among  the  sixty  cases  reported  by  Chattet  in 
1909,  it  is  interesting  to  note  that  there  were  only  four 
cases  which  developed  after  two  injections  (Desplas, 
Cazin  and  Leriche),  and  even  in  these  cases  the  two 
injections  were  given  at  an  interval  of  twenty-five  days. 


TREATMENT  SCy9 

We  have  already  considered  the  special  development 
of  certain  forms  of  tetanus  subsequent  to  preventive 
serotherapy,  and  need  not  further  insist  upon  it  here. 
Under  these  conditions  tetanus  may  be  local,  and  its 
onset  insidious  and  precocious  ;  often,  on  the  other 
hand,  it  is  late  in  making  its  appearance.  It  follows 
that  in  the  case  of  every  doubtful  wound  there  is  reason 
to  administer  a  second  injection  eight  days  after  the 
first,  and  that  in  the  case  of  contused  wounds  it  is 
advisable  to  give  three  or  four  injections,  at  eight  days' 
interval.  This  brief  interval  between  the  various  in- 
jections has  the  additional  advantage  of  protecting  the 
patient  against  anaphylactic  symptoms.  We  know, 
indeed,  that  these  s\TTiptoms  occur  eight  to  ten  days 
after  the  first  injection,  and  that  their  onset  assumes 
the  form  either  of  erji:hema  or  arthralgia,  or  respira- 
tory disorders  which  pulmonary  examination  fails  to 
justify.  It  is  then  that  the  three  orders  of  symptoms 
appear  which  are  characteristic  of  the  anaphylactic 
state,  and  which,  if  they  occur,  should  by  themselves 
lead  the  physician  to  diagnose  anaphylaxis.  They  are, 
to  recapitulate  : 

1.  Modifications  of  the  pulse.  These  are  variable  ; 
acceleration  of  the  pulse  is  a  constant  symptom,  but 
sometimes  it  is  not  only  rapid,  but  small  and  irregular, 
while  sometimes  it  is  unequal  and  intermittent. 

2.  Modifications  of  the  respiration,  which  consist  of 
an  extraordinary  amplitude  of  the  respiratory  move- 
ments. Sometimes  the  inspiration  alone  is  prolonged 
and  difficult,  expiration  taking  place  suddenly  and 
noisily,  and  being  followed  by  a  ver\^  long  pause.  In 
certain  cases  stertor  may  be  noted,  or  Cheyne-Stokes 
breathing. 

3.  Coma   completes   the   clinical   picture   and   con- 


870       THE  ABNORMAL  FORMS  OF  TETANUS 

stitutes,  in  association  with  the  modification  of  the 
pulse  and  the  temperature,  the  bulbar  syndrome  of 
anaphylaxis.  Sometimes  this  coma  makes  a  sudden 
appearance  ;  sometimes  it  is  preceded  By  a  period  of 
somnolence,  of  apathy,  of  semi-coma.  Its  appearance, 
as  a  rule,  follows  that  of  the  disorders  of  the  pulse  and 
the  respiration.     It  announces  the  terminal  period. 

In  addition  to  the  bulbar  syndrome,  sphincter  dis- 
orders and  convulsions  have  been  reported. 

The  development  of  these  anaphylactic  symptoms 
may  end  in  death  or  recovery. 

With  regard  to  late-appearing  tetanus,  if  we  carefully 
analyse  the  observations  published  by  Berard  and 
Lumi^re,  it  seems  probable  that  in  many  cases  inocula- 
tion was  effected  at  the  moment  of  the  latest  surgical 
intervention.  Accordingly,  even  those  patients  who 
haie  received  the  two  regulation  injections  shortly  after 
being  wounded  should  be  given  a  fresh  dose  of  anti- 
tetanic  serum  whenever  it  becomes  necessary  to  resort 
to  surgical  intervention,  as  this  may  result  in  the  libera- 
tion of  the  septic  products  latent  in  a  suspect  wound. 
Since  Berard  and  Lumi^re  have  applied  this  rule  they 
have  observed  no  further  cases  of  late  infection. 

What  is  now  the  dose  of  serum  which  should  be 
injected  preventively  ?  In  France  the  serum  supplied 
by  the  Pasteur  Institute  is  employed.  Of  this  at  least 
10  c.c.  should  be  injected  as  a  dose.  Certain  physicians 
increase  the  amount  for  the  first  dose,  injecting  15  c.c. 
or  20  c.c.  the  first  time  ;  others  recommend  the  in- 
jection of  10  c.c.  daily  for  the  first  three  days. 

If  the  American  serum  be  employed,  the  usual  dose  is 
again  10  c.c. 

Lastly,  the  prophylactic  serum  should  be  ad- 
ministered subcutaneously. 


TREATMENT  871 

An  Adjuvant  to  the  Prophylactic  Serum. — Salol. — 
Certain  writers  recommend  the  employment,  in  addi- 
tion to  the  antitoxin,  of  large  doses  of  salol — 4  to  6 
grammes  daily — as  a  preventive.  Although  the  effect 
of  this  medication  is  doubtful,  the  drug  may  be  utilised 
(being  inoffensive),  especially  if  there  is  a  dearth  of 
serum. 


Curative  Treatment 

When  the  first  signs  of  tetanus  appear — trismus  and 
contractures,  generalised  or  localised — it  is,  of  course, 
too  late  for  prophylactic  measures.  We  must  en- 
deavour to  cure,  or  to  struggle  against,  the  declared 
tetanic  infection.  The  treatment,  then,  must  be 
specific  ;  we  must  resort  either  to  antitetanic  serum  or 
to  injections  of  carbolic  acid.  At  the  same  time  the 
treatment  should  be  symptomatic,  and  the  clinician 
must  endeavour  to  find  remedies  for  the  accidents  of 
tetanus  :    contractures,  pains,  and  asphyxia. 

Local  Treatment. — Before  discussing  the  various 
methods  employed  in  the  treatment  of  tetanus,  it  must 
be  remembered  that  the  tetanigenous  wound  must  not 
be  neglected,  but  must  be  treated.  As  in  the  prophy- 
lactic treatment  of  wounds,  it  must  undergo  disinfec- 
tion, clearing  out,  and  drainage.  The  usual  antiseptics 
already  mentioned  will  be  employed.  Insufflations  of 
oxygen  may  also  be  employed,  with  the  oxidising 
agents,  oxygenated  water,  carbolic  acid,  and  light ; 
they  are  not,  as  a  rule,  very  effective.  It  must  also  be 
remembered  that  in  some  cases  amputation  results  in  a 
mitigation  of  serious  symptoms. 

The  physician  should  always  search  for  projectiles  ; 
a  great  improvement  has  sometimes  been  observed  after 


S72        THE  ABNORMAL  FOIUIS  OF  TETANUS 

the  removal  of  foreign  bodies  (usually  shell-splinters) 
on  which  the  tetanic  bacillus  has  been  found. 

Specific  Treatment — Curative  Antitetanic  Serotherapy. 
— Certain  writers  question  the  curative  value  of  the 
serum  ;  in  any  case  it  is  less  clear  than  its  preventive 
action.  From  their  experiments  upon  animals,  Roux 
and  Vaillard  had  already  concluded  that  antitetanic 
serum  possessed  no  curative  action  on  declared  tetanus. 
When  indeed,  the  first  symptoms  make  their  appear- 
ance "  the  toxin  elaborated  at  the  centre  of  infection 
has  reached  the  nervous  centres,  and  these  may  be  so 
far  invaded  that  death  inevitably  ensues.  Certainly 
the  antitoxin  injected  under  the  skin  or  into  the  peri- 
toneiun  neutralises  the  toxin  in  circulation,  but  it  does 
not  remedy  the  lesions  produced,  and  can  do  nothing 
against  ^n  accomplished  poisoning  "  (Vaillard). 

The  experiments  of  Xocard  have  also  demonstrated 
that  the  serum  has  no  modifying  action  upon  confirmed 
tetanus.  However,  when  injected  into  the  brain  itself 
(intra-cerebral  injection)  it  may  produce  a  successful 
result. 

Thus  Roux  and  Borrel  conceived  the  idea  of  bringing 
the  serum  directly  into  contact  with  the  nervous 
substance,  and  in  guinea-pigs  which  had  been  rendered 
tetanic  the  intra-cerebral  injection  of  the  serum  arrested 
the  development  of  the  tetanus,  and  the  animals  re- 
covered. We  shall  presently  consider  the  value  of  this 
method  in  human  therapeutics. 

Good  results  may  also  be  obtained  by  injecting  the 
serum  in  the  neighbourhood  of  the  nervous  centres. 
Thus,  parabulbar  injections  have  produced  7  recoveries 
out  of  13  cases  in  the  dog  (Camus). 

However  this  may  be,  if  we  analyse  the  various 
statistics  relating  to  curative  serotherapy  our  judgment 


TREATMENT 


873 


is  predominantly  favourable  ;  the  curative  action  of  the 
serum  cannot  be  denied.  Thus,  according  to  a  first 
series  of  statistics,  among  190  cases  treated  without 
serum  the  mortality  was  79  per  cent. ;  among  330  cases 
treated  with  serum  it  was  only  62*1  per  cent. 

In  a  second  series  of  statistics  15  cases  treated  with- 
out serum  (an  admixture  of  slight  cases  and  cases  in 
extremis)  yielded  3  recoveries  and  12  deaths  ;  while  152 
cases  treated  by  antitoxin  yielded  47  recoveries  and 
105  deaths. 

If  we  combine  the  observations  recently  published 
by  Comby,  Massary,  Roger,  Reals  and  Thomy,  and 
Etienne,  with  the  table  which  the  last  writer  published 
in  1900,  we  have  a  manifest  proof  of  the  efficacy  of 
serotherapy  in  declared  tetanus.  We  reproduce 
Etienne's  table  ;  it  is  based  on  the  period  of  incubation. 


Incubation 

Recoveries 

Deaths 

Mortality 

Mortality  before  the  Intro- 

duction  of  Serotherapy, 

according  to  Brunner 

1  to    5  days   . 

5  to  10  ,,  . 
10  to  12  „  . 
Over  12    „      . 

3 

20 

7 

15 

7 
7 
1 
1 

70% 
29% 
13-3% 
6-6% 

90% 

70% 

Haushalter,  employing  the  method  of  massive  injec- 
tions, has  published  statistics  of  32  cases,  in  which  he 
was  able  to  determine  the  length  of  the  incubation 
period.  Although  these  statistics  were  obtained  under 
bad  conditions,  since  they  refer  to  men  wounded  in 
battle,  many  of  whom  were  left  for  several  days  on  the 
battle-field,  or  to  men  taken  to  hospital  while  the 
tetanic  paroxysms  were  at  their  height,  this  table  (p.  194) 
is  particularly  instructive. 


874      THE  ABNORMAL  FORMS  OF  TETANUS 

In  the  military  hospital  at  Nancy,  L.  Spillmann 
observed  a  mortality  of  50  per  cent,  in  the  group  of 
cases  for  which  he  was  able  to  employ  serum,  or  9 
deaths  and  9  recoveries,  5  of  these  latter  being  cases  of 
subacute  tetanus  and  4  of  acute  tetanus. 

In  curative  serotherapy  the  surgeon  should  : 
1.  Commence  the  treatment  as  early  as  possible — - 
directly  the  slightest  symptoms  make  their  appearance. 


Incubation 

Recoveries 

Deaths 

Mortality 

5  daj's .... 

1 

2 
2f 

7  , 

8  , 

9  , 

"i 
1 

62-5% 

10    , 

7 

8) 

11     , 

2 

1 

43% 

12    , 

3 

...) 

13    , 

1 

\ 

14    , 

1 

. 

0 

16    , 

2 

...  j 

Of  among  33  cases 

19 

14 

42-5% 

2.  Employ  massive  doses  of  cerum^  without,  how- 
ever, exaggerating  them  ;  we  shall  return  to  this  point 
when  discussing  the  various  modes  of  treatment. 

Modes  of  Treatment. — The  antitetanic  serum  may  be 
introduced  into  the  system  in  several  ways,  which  we 
shall  proceed  to  describe  :  under  the  skin,  into  the 
muscles,  into  the  veins,  into  the  arteries,  into  the  spinal 
cavity,  and  into  the  cranial  cavity. 

Subcutaneous  Injections. — Surgeon- General  (M6decin- 
Inspecteur)  Chavasse  has  reported  excellent  results 
obtained  by  the  employment  of  antitetanic  serum  in 
subcutaneous  injections,  the  dose  being  60  c.c.  to  100 
c.c,  divided  into  two  injections  per  diem,  and  repeated 
for  two  or  three  successive  days. 


TREATMENT  875 

According  to  the  majority  of  clinical  writers,  50,  80, 
or  100  c.c.  of  serum  should  be  injected  the  first  day,  and 
then  40  to  50  c.c.  daily,  this  being  continued  for  at 
least  eight  days.  It  should  be  mentioned  that  this  is 
the  method  least  likely  to  give  rise  to  seric  accidents  and 
anaphylaxis.     We  shall  return  to  this  point  later  on. 

In  any  case,  the  intensive  doses  should  be  continued 
as  long  as  the  tetanic  symptoms  persist,  but  as  the 
quantity  of  heterogeneous  serum  injected  is  not  a 
negligible  element,  and  as  anaphylactic  accidents  occur 
principally  after  heavy  doses,  we  think  it  possible  to 
apply  an  efficacious  serotherapeutic  medication  without 
employing  such  massive  doses,  for  the  injection  of 
exaggerated  doses  may  become  a  danger. 

The  treatment  by  subcutaneous  injection  is  regarded 
by  certain  foreign  writers  (Germans)  as  of  illusory  value, 
and  they  employ  it  only  as  an  accessory  means.  They 
inject  the  serum  in  the  periphery  of  the  woimd,  or  they 
introduce  the  bulk  of  the  serum  into  the  system  by  intra- 
venous or  intralumbar  injection,  making  injections  in 
the  region  of  the  wound  merely  in  order  to  augment  the 
dose  thus  injected. 

Intramuscular  Injections. — Recommended  by  certain 
writers  ;  this  method  does  not  appear  to  us  to  be 
advisable. 

Intravenous  Injections. — Recommended  by  Jose 
Penna  in  particular,  many  clinical  writers  regard  these 
as  constituting  the  best  method  of  treatment.  Intra- 
venous injections  should  possess  the  advantage  of  being 
more  active  than  subcutaneous  injections.  Still,  it 
must  be  remembered  that  intravenous  injections  are 
more  liable  to  provoke  anaphylactic  shock,  and  we  con- 
sider, with  Camot,  that  their  therapeutic  superiority 
is  by  no  means  established.    We  know  that  in  studying 


876      THE  ABNORMAL  FORMS  OF  TETANUS 

the  anaphylactic  shock  experimentally  the  liberating 
dose  administered  to  animals  prepared  by  a  previous 
injection  is  administered  by  intravenous  injection. 
The  intravenous  injection  of  a  very  small  quantity  of 
serum  suffices  to  cause  the  immediate  appearance  of 
violent  symptoms,  which  closely  resemble  those  which 
Carnot  recorded  in  his  patient,  the  observation  of  whose 
case  we  have  already  reproduced  in  detail.  The 
rapidity  and  violence  of  the  anaphylactic  shock, 
the  hypotension,  the  cardiac  derangement,  and  the 
cyanosis  are  such  that  we,  like  Carnot,  never  give  intra- 
venous injections  of  serum  to  patients  who  have  already 
been  inoculated,  no  matter  what  the  date  of  the  previous 
inoculation.  Moreover,  it  results  from  the  interesting 
experiments  of  Jean  Camus  that  while  curative  anti- 
tetanic  serotherapy  produces  visible  effects  during  the 
course  of  declared  tetanus,  the  results  produced  by 
intravenous  injection  are  in  no  way  superior  to  those 
obtained  by  subcutaneous  injection. 

Whatever  may  be  the  truth  of  this  criticism,  the 
partisans  of  this  method  recommend  the  introduction 
into  the  circulation  of  100  c.c.  of  senmi  at  the  first  in- 
jection, this  dose  being  followed  by  one  of  40  c.c. 

Walter,  Barnsby,  and  Mercier  recommend  injections 
decreasing  from  50  c.c.  to  10  c.c,  associated  with  intra- 
venous injections  of  chloral.  These  authors  are  said  to 
have  obtained  6  recoveries  out  of  8  cases. 

Lemonnier  reports  a  total  mortality  of  42  per  cent., 
with  8  recoveries  out  of  19  cases  of  acute  tetanus. 
Morax,  Achard,  Castaigne,  and  Touraine  and  Francon 
have  obtained  successful  results.  Torres,  in  Buenos 
Aires,  reports  a  mortality  of  32  per  cent,  for  110  cases. 
He  injected  120  c.c.  in  the  first  place,  and  afterwards 
100  c.c. 


TREATMENT  877 

Certain  writers  recommend  that  the  injections  should 
be  warmed,  as  accidents  are  said  to  be  avoided  if  this  is 
done.  According  to  the  same  writers,  by  the  repetition 
of  injections  every  two  hours  an  immediate  action  of 
the  serum  may  be  noted.  The  general  contracture  of 
the  muscles  is  said  to  be  influenced  but  slightly,  or  not 
at  all,  but  the  cramps  are  said  to  lose  visibly  in  fre- 
quency and  intensity.  Finally,  the  action  of  the  serum 
is  said  to  be  more  rapid  than  when  administered  by 
intralumbar  injection. 

In  this  connection,  one  writer  even  went  so  far  as  to 
treat  a  man  suffering  from  a  wound  in  the  elbow,  in- 
flicted by  a  shell- splinter,  and  complicated  by  tetanus, 
by  means  of  strong  doses  of  serum,  administered  by 
subcutaneous  and  intravenous  injection,  which  were 
continued  until  the  appearance  of  anaphylactic 
symptoms.    The  wounded  man  recovered. 

Despite  these  encouraging  data,  we  think  it  as  well 
to  repeat  that  for  the  reasons  already  given  we  do  not 
as  a  general  rule  recommend  intravenous  injection. 

Intra-arterial  Injections. — Heddaus  has  recom- 
mended intra-arterial  injections,  for  the  reason  that  the 
arterial  circulation  forms  the  most  direct  and  efficacious 
path  to  the  brain.  The  technical  method  employed  is 
the  following  :  the  carotid  artery  is  laid  bare,  under 
either  general  or  local  anaethesia,  and  the  needle  is 
plunged  into  it  obliquely  in  the  direction  of  the  blood- 
current.  The  serum  is  thus  injected  into  the  blood. 
In  no  case  have  there  been  disagreeable  accidents.  The 
small  wound  is  closed  with  three  or  four  Michel's  clamps. 

In  France  this  method  of  carotid  injections  has  been 
employed  by  Gauthier  and  Chattot.  But  as  we  have 
already  remarked,  the  injection  of  the  serum  into  the 
blood-stream  does  not  yield  better  results  in  the  treat- 


878       THE  ABNORMAL  FORMS  QF  TETANUS 

merit  and  cure  of  tetanus,  and  we  therefore  reject  it  as 
dangerous  and  complicated. 

Inira-cerebral  Injeciion. — This  method,  which  experi- 
mentally is  infallible,  according  to  the  investigations  of 
Roux  and  Borrel,  has  not,  with  human  subjects,  given 
the  results  which  one  might  have  expected  from  it. 

Clinically  speaking,  failures  are  numerous,  and  indeed 
the  rule  ;  moreover,  a  considerable  number  of  serious 
and  sometimes  fatal  accidents  may  occur  (delirium, 
epileptiform  convulsions,  etc.).  It  is  said  that  recent 
statistics  have  yielded  52  fatal  cases  out  of  84. 

Intra-cerebral  injection  is  not  at  present  prg-ctised. 

Sub- arachnoid  Injection. — This  method,  employed 
principally  abroad,  has  been  recommended  in  France  by 
Doyen.  This  surgeon  is  said  to  make  intra-rachidian 
injections  of  60  c.c.  the  first  day,  and  40  c.c.  the  second 
day.  He  makes  his  patient  lie  in  a  bulbar  declivity  of 
forty-five  degrees,  claiming  that  the  serum  in  this  way 
reaches  the  nervous  centres.  He  is  said  to  have  lost 
3  patients  out  of  24  treated,  thus  obtaining  a  death-rate 
of  12  per  cent. 

In  England  Dr  John  Eyre,  of  London,  and  Dr  Blair 
regard  intra-rachidian  injection  as  the  best  method  of 
treating  tetanus. 

Clinically  speaking,  it  must  be  remembered  that 
lumbar  punctures  are  very  difficult  in  tetanus  patients — 
even  impossible,  except  under  general  ansethesia,  under 
chloroform  by  preference,  in  order  to  avoid  broncho- 
pulmonary complications.  This  intervention  becomes 
a  difficult  complication  in  a  contractured  patient,  for 
whom  the  most  absolute  repose  is  a  fundamental 
necessity.  Moreover,  the  injection  may  cause  a  slight 
inflammation  of  the  serous  membrane.  Aseptic  puri- 
form   meningeal   reactions  (Widal,   Sicard  and  Salin) 


TREATMENT  879 

are  exceptional  with  French  serum.  However,  when 
aseptic  scric  meningitis  does  result,  the  symptoms 
develop  in  the  following  order.  Three  or  four  hours 
after  the  injection,  headache  makes  its  appearance, 
together  with  a  trace  of  Kernig's  sign.  The  symptoms 
reach  their  maximum  severity,  according  to  Sicard  and 
Salin,  about  the  fifth  or  sixth  hour,  then  becoming 
gradually  attenuated  and  disappearing  on  the  second 
day.     Examination  of  the  cerebro-spinal  fluid  shows  : 

1.  The  presence  of  polynuclear  leucocytes,  which  are 
intact,  and  are  not  modified  as  at  the  commencement  of 
an  infectious  meningitis. 

2.  The  presence  of  red  corpuscles  in  abundance. 

3.  At  other  times  the  liquid  is  found  to  have  changed 
colour,  being  thick,  opalescent,  puriform. 

This  aseptic  serum  meningitis  is  never  fatal. 

Intra-nervous  Injection. — Guided  by  Mayer  and 
Ramson's  experiments  upon  animals,  certain  physicians 
have  tried  intra-nervous  injections,  with  a  view  to 
checking  the  invasion  of  the  nerves  by  the  toxin. 
Thus,  the  case  has  been  reported  of  a  laboratory  attend- 
ant, \vho  is  said  to  have  been  saved  by  an  injection  of 
serum  in  the  brachial  plexus.  These  injections  are 
said,  moreover,  to  obviate  the  amputation  of  a  limb. 
It  is  obvious  that  the  introduction  of  the  antitoxin  into 
the  nerves  is  effected  more  certainly  if  the  brachial 
plexus  is  previously  laid  bare  below  the  clavicle,  the 
sciatic  nerve  in  the  bend  of  the  thigh,  or  the  crural 
nerve  in  the  crease  of  the  groin.  In  thin  subjects  this 
uncovering  of  the  nerve  is  easy,  and  the  serum  may  then 
be  injected  into  it,  but  this  method  sometimes  aggra- 
vates the  local  tetanus  of  a  wounded  extremity.  In 
France  two  principal  methods  have  been  employed  of 
acting  upon  the  nervous  trunks  which  conduct  the  toxin 


880        THE  ABNORMAL  FORMS  OF  TETANUS 

from  the  wound  to  the  medullary  and  cerebral  nervous 
centres. 

These  are  :  the  para-nervous  injections  recommended 
by  Sicard,  which  are  made  at  the  root  of  the  limb,  in  the 
neighbourhood  of  the  nerves ; 

The  para-radicular  injections  of  Apert  and  Lhermitte, 
which  are  administered  epidurally  in  the  sacral  region. 
They  offer  a  double  advantage  :  in  the  first  place,  they 
are  less  difficult  to  give  than  the  preceding  kind,  and 
they  surround  all  the  nerve  trunks  proceeding  from  the 
lumbar  and  the  sacral  plexus  with  antitoxin,  while  the 
serum  is  not  diluted  as  it  is  in  the  cerebro- spinal  fluid. 
Vautrin,  however,  has  been  unable  to  discover  that  this 
method  is  of  any  greater  efficacy. 

Injections  of  serum  in  immediate  contact  with  the 
wound  have  also  been  recommended.  Thus,  in  four 
cases,  Jousset  conceived  the  idea  of  administering  deep 
injections  of  20  to  30  c.c.  of  serum  about  the  pharynx, 
in  the  submaxillary  region.  These  injections  calmed 
the  trismus  and  the  dysphagia. 

Of  all  these  methods,  one  in  particular  is  above  all 
criticism — namely,  the  subcutaneous  method.  It  is  not 
sufficient  by  itself  to  cure  tetanus,  which  demands,  as 
we  shall  see,  a  combined  treatment.  And  although  no 
one  method  has  proved  itself  to  possess  such  efficacy 
as  to  impose  itself  above  ail  the  rest,  we  have  deemed  it 
of  interest  to  recapitulate  the  various  methods  which 
have  been  successively  employed  in  curative  sero- 
therapy. 

Antitoxic  Treatment 

Treatment  by  Carbolic  Acid  (BacelWs  Treatment). — 
Bacelli,  in  1888,  advised  the  subcutaneous  injection,  in 
cases  of  tetanus,  of  carbolic  acid  in  a  2  or  3  per  cent. 


TREATMENT  881 

solution.  The  injections  should  be  given  several  times 
a  day  until  the  tetanus  has  terminated  (twenty  days 
and  more),  each  injection  containing  -03  to  -04 
gramme  of  carbolic  acid. 

The  happy  results  obtained  by  this  treatment  might 
point,  according  to  some  writers,  to  the  fact  that  the 
cases  treated  were  not  severe.  By  this  method  at  least 
1  gramme,  and  even  more,  of  carbolic  acid  must  be 
introduced  into  the  system.  The  injections  are  not 
very  painful,  and  are  not  accompanied  by  any  renal 
symptoms. 

In  the  majority  of  cases,  about  half-an-hour  after  the 
first  injection,  a  sedative  effect  is  produced,  with  a 
diminution  of  the  contractures.  This  phenomenon,  mani- 
fested more  particularly  in  cases  of  little  gravity,  is  said 
to  be  more  readily  obtained  with  sulphate  of  magnesium. 
Consequently,  certain  writers  consider  that  the  carbolic 
acid  treatment  should  be  reserved  for  very  slight  cases. 

To  avoid  any  caustic  action,  certain  physicians 
employ  oily  solutions  (Margliano,  Gerest,  de  Montille, 
Lesage). 

In  France  this  treatment  is  frequently  employed, 
above  all  in  combination  with  serotherapy  (de  Massary, 
Roullaud,  Goumez,  Laurent),  or  alone  (Caillaud, 
Cornoglion,  Migay),  or  in  association  with  chloral 
(Sainton). 

Sainton  recommends  the  following  procedure: 
Twice  a  day  the  patient  is  given  an  injection  of  40  c.c. 
to  50  c.c.  of  a  2  per  cent,  solution  of  carbolic  acid,  so 
that  the  daily  dose  varies  between  1-6  grammes  and  2 
grammes.  The  injection  is  subcutaneous,  and  is  given, 
preferably,  above  the  seat  of  the  wound  and  in  its 
neighbourhood.  The  injections  may  be  contmued  for 
several  days,  and  in  the  case  of  two  patients  Sainton 


882        THE  ABNORMAL  FORMS  OF  TETANUS 

continued  the  treatment  for  nearly  a  month  ;  and  he 
has,  in  two  cases,  introduced  48  grammes  of  carboUc 
acid  into  a  patient's  system  without  provoking 
symptoms  of  poisoning.  The  urine,  in  particular, 
never  exhibited  the  characteristic  black  tinge.  By 
this  method,  in  association  with  chloral  (12  to  16 
grammes  daily  in  two  enemas),  Sainton  obtained 
positive  results,  although  in  two  cases  which  termin- 
ated in  recovery  the  symptoms  had  assumed  a  very 
grave  development. 

Intravenous  and  intra- spinal  injections  have  not 
been  much  investigated. 

Two  writers  have  made  experimental  investigations 
with  animal  subjects,  in  order  to  determine  whether 
carbolic  acid  has  a  prophylactic  action.  In  mice 
previously  injected  with  carbolic  acid  they  succeeded 
in  attenuating  the  tetanic  infection,  in  retarding  death, 
and  even  in  averting  it.  Carbolic  acid,  then,  should 
possess  prophylactic  and  not  merely  curative  properties. 

Mode  of  Action  of  Carbolic  Acid. — It  is  said  to  act  on 
both  the  serum  and  the  toxin. 

In  vitro,  it  is  said  to  annul  the  toxic  action  of  a  large 
dose  of  a  culture  of  tetanic  bacilli. 

In  vivo  experiment  hardly  bears  out  the  hypothesis 
of  action  upon  the  toxin  ;  it  does  not  modify  experi- 
mental tetanus.  'At  the  same  time,  successful  results 
haye  been  obtained  in  human  tetanus. 

Thus,  in  the  case  whose  particulars  were  published 
by  Stewart  and  Laing  in  The  Lancet,  26th  December 
1914,  the  tetanus  became  aggravated  in  spite  of  large 
doses  of  serum,  chloral,  and  bromide  ;  it  was  cured  in 
a  month  as  a  result  of  the  subcutaneous  injection  of 
carbolic  acid  (2  c.c.  of  a  5  per  cent,  solution  every  two 
hours,  under  the  skin  of  the  abdomen). 


TREATMENT  883 

Colloidal  Metals. — As  an  antitoxic  treatment,  the 
colloidal  metals  might  be  employed :  collargol, 
electrargol,  lantol,  coUoidal  gold. 

Alcohol. — As  chemical  substances  might  exert  a 
detrimental  action  on  the  antitoxin,  alcohol  has  been 
suggested  and  recommended,  as  it  should  act  as  a 
narcotic. 

Dutertre,  in  this  connection,  mentions  a  case  of 
tetanus  which  he  had  occasion  to  observe  some  twelve 
years  ago  in  the  hospital  at  Boulogne-sur-Mer.  The 
patient  was  a  vagrant,  who,  subsequently  to  a  wound 
in  the  face,  inflicted  by  a  kick,  was  attacked  by  tetanus. 
Some  comrades  who  called  to  see  him  secretly  brought 
him  a  litre  of  brandy,  of  which  he  drank  every  drop,  so 
that  by  the  evening  he  was  dead  drimk. 

Next  day  the  patient  was  better,  and  a  few  days 
later  he  left,  cured.  Dutertre  compares  the  result 
obtained  by  alcohol  in  this  case  with  the  result  obtained 
in  cases  of  snake-bite.  We  know  that  many  persons 
bitten  by  venomous  snakes  have  made  themselves 
drunk,  and  have  escaped  death. 

As  Dutertre  remarks,  the  arterial  tension,  being  in- 
creased by  the  absorption  of  a  large  quantity  of  alcohol, 
may  perhaps  retard  the  toxin  production  of  the  wound. 
Perhaps,  also,  the  presence  of  a  certain  amount  of 
alcohol  in  the  blood  annihilates  the  action  of  the 
tetanic  toxin. 

Salvarsan. — Favourable  results  have  been  reported 
from  the  employment  of  salvarsan  in  cases  of  tetanus. 
In  the  two  first  cases  the  employment  of  salvarsan  was 
associated  with  the  antitoxin  treatment ;  the  patients 
recovered.  Of  six  other  patients,  two  presenting  a 
tetanus  of  medium  severity  recovered  after  the  em- 
ployment of  salvarsan. 


884       THE  ABNORMAL  FORMS  OF  TETANUS 

The  four  remaining  cases  of  tetanus  were  of  a  serious 
character.  Treated  by  salvarsan,  one  died  of  pneu- 
moiiia  ;  one  recovered ;  the  two  remaining  cases 
showed  great  improvement. 

The  writer  who  reports  these  results  believes  that 
salvarsan  acts  favourably  upon  tetanus.  The  grave 
and  rapid  development  of  tetanus  is  said  to  become 
milder  and  slower,  and  the  duration  longer.  It  is 
possible,  says  this  writer,  that  salvarsan  alone  would 
act  in  the  same  way  as  antitetanic  serum. 

According  to  him,  the  treatment  should  commence 
with  antitoxin  directly  tetanus  is  declared,  and  salvar- 
san should  be  given  on  the  second  and  perhaps  the 
third  day.  Two  injections  of  '05  gramme  of  salvarsan 
should  suffice. 

Other  writers  have  made  investigations  in  order  to 
judge  of  the  value  of  this  treatment,  and  it  must  be 
recognised  that  a  number  of  cases  have  not  been 
favourably  affected  by  salvarsan. 

The  results  at  present  being  what  they  are,  we  do 
not  advise  the  employment  of  this  drug  in  tetanus, 
whatever  the  clinical  appearance  or  severity  of  the 
disease. 

Ascitic  Fluid. — ^The  injection  of  a  serous  exudate  in 
cases  of  tetanus  might,  according  to  certain  writers, 
lead  to  an  amelioration  of  the  dangerous  symptoms. 
The  liquid  to  be  injected  is  collected  in  a  sterilised 
flask  and  injected  five  to  ten  minutes  later.  This 
serous  exudate  is  rich  in  lymphoid  cells  and  albumin. 

Other  Antitoxic  Agents. — Among  the  substances 
capable  of  neutralising  the  toxin  in  vitro,  hydrochlorate 
of  betain  has„been  suggested  (Jaboulay),  an4  choles- 
terin.  which  is  said  to  fix  the  toxin  in  the  nervous 
system.     Nervous   opotherapy   has  also  been   recom- 


TREATMENT  S85 

mended,  this  suggestion  being  inspired  by  a  mistaken 
interpretation  of  the  experimental  results  obtained  by 
Wassermann  and  Takaki  in  respect  of  the  neutralisa- 
tion of  the  toxin  by  cerebral  pulp. 

A.  Lumi^re  and  Chevrotier  have  investigated  the 
action  of  oxidising  agents  on  the  tetanic  toxin,  and 
their  experiments,  conducted  first  in  vitro,  then  in 
vivo,  with  the  guinea-pig,  dog,  goat,  and  ass,  have  led 
them  to  the  conclusion  that  among  the  many  substances 
tested  the  alkaline  persulphates  possess  in  the  highest 
degree  the  property  of  exerting  a  destructive  action  on 
toxins. 

Guinea-pigs  which  are  given  subcutaneous  injections 
of  a  solution  of  sodium  persulphate  some  minutes  or 
some  hours  after  the  injection  of  the  toxin  always  sur- 
vive the  experiment.  The  period  of  survival  varies 
according  to  the  dose  of  toxin  administered. 

Persulphate  of  sodium,  according  to  Lumidre  and 
Chevrotier,  exerts  a  constantly  favourable  action 
upon  the  paroxysms  of  contracture,  alleviating  or 
even  suppressing  them.  The  remarkable  effect  of  the 
persulphates  upon  the  tetanic  spasm  having  been 
thoroughly  verified  in  man,  these  writers  have  em- 
ployed this  method  in  all  their  cases  of  tetanus. 

The  treatment  consists  in  injecting  20  c.c.  of  a  5  per 
cent,  solution  of  pure  neutral  persulphate  of  sodium 
intravenously,  once  or  twice  a  day,  according  to  the 
gravity  of  the  infection.  These  injections  may  be  con- 
tinued for  eight  to  fifteen  days,  their  frequency  being 
regulated  according  to  the  development  of  the  spas- 
modic symptoms  ;  they  are  given  at  longer  intervals 
when  the  paroxysms  cease,  but  more  frequently  if 
they  persist. 

The   persulphate    should   be    kept    protected    from 


88G      THE  ABNORMAL  FORMS  OF  TETANUS 

damp,  and  in  the  solid  state,  in  sealed  tubes  containing 
quantities  of  5  grammes.  In  solution  it  keeps  only  for 
a  few  days,  and  the  solution  is  decomposed  by  heat. 
It  should  therefore  be  prepared  as  required,  by  dissolv- 
ing each  dose  of  5  grammes  in  100  c.c.  of  cold  distilled 
and  sterilised  water. 

When  a  solution  is  not  employed  within  a  week  it 
should  be  thrown  away. 

The  intravenous  injection  of  this  drug  does  not,  as 
a  rule,  cause  any  reaction.  However,  nausea  is  some- 
times observed  two  or  three  minutes  after  the  injection, 
and  it  may  be  accompanied  by  vomiting,  which  is, 
however,  unimportant. 

Immediately  after  the  administration  of  this  medi- 
cament the  paroxysms,  as  a  rule,  cease,  or  are  at  least 
greatly  attenuated.  The  permanent  contractures,  and 
notably  the  trismus,  persist  without  modification. 
According  to  Lumi^re  the  patients  themselves  beg  for 
the  injections,  of  which  they  quickly  feel  the  results. 
They  become,  moreover,  insensitive  to  external  excita- 
tions, and  no  longer  exhibit  the  afflicting  paroxysms 
which  make  tetanus  one  of  the  most  appalling  and 
formidable  of  diseases. 

Bottu's  Mixture. — Routier  recommends,  in  addition 
to  the  usual  treatment  with  morphine  and  chloral, 
which  fails  in  a. great  many  cases,  the  employment  of 
subcutaneous  injections  of  a  saline  mixture  furnished 
by  M.  Bottu. 

This  saline  mixture  is  composed  of  pure  and  very 
stable  persulphate  of  sodium,  and  phosphate  of  calcium 
sufficiently  rich  in  free  phosphoric  acid  to  render  the 
whole  soluble  in  ten  parts  of  water. 

This  preparation  takes  the  form  of  a  white  crystalline 
powder,  odourless,  with  an  acid  flavour   which  keeps 


TREATMENT  887 

perfectly  without  giving  off  oxygen,  as  do  the  com- 
mercial persulphates  of  sodium,  which  are  always 
more  or  less  decomposed,  and,  moreover,  contain  an 
often  large  proportion  of  sulphate  of  am^monium.  The 
mixture  contains  one-fourth  of  its  weight  of  phosphoric 
acid  (H3PO4).  This  powder  is  completely  soluble  in 
distilled  water,  but  should  not  be  dissolved  until  the 
moment  it  is  required  when  employed  for  subcutaneous 
injections. 

In  this  way  small  reserves  are  injected  into  the 
system,  which,  by  their  slow  decomposition,  furnish 
oxygen  and  phosphoric  acid  almost  continuously. 

Subcutaneous  injections  of  Bottu's  mixture  are  given 
three  times  daily,  the  dose  being  50  centigrammes  of  the 
salt  dissolved  in  6  c.c.  of  distilled  water.  According 
to  Routier  a  careful  watch  should  be  kept  on  the 
patient,  for  in  his  opinion  this  treatment  predisposes  to 
pulmonary  congestion. 

These  injections  are  rather  painful,  but  they  appear 
to  arrest  the  pains  and  contractures.  Thus,  in  the  case 
of  the  soldier  of  the  8th  Colonial  Regiment,  observed  by 
Routier,  of  which  we  have  already  given  the  par- 
ticulars, the  cessation  of  the  injections  of  Bottu's  saline 
mixture,  although  the  chloral  was  continued,  was 
followed  by  the  reappearance  of  the  pains  and  contrac- 
tures, which  ceased  when  the  injections  were  resumed. 

To  render  these  injections  less  painful,  Routier 
recommends  the  addition  of  a  third  of  a  Pravaz' 
syringeful  of  morphia  (1  per  cent.)  to  the  saline  solution. 

Symptomatic  Treatment 

Hygiene.- — Whether  the  development  of  the  disease 
is  classical  or  atypical,  the  hygienic  precautions  which 


888      THE  ABNORMAL  FORMS  OF  TETANUS 

such  a  malady  calls  for  are  so  well  understood  that 
we  need  not  dwell  upon  them  here.  We  will  merely 
remind  the  reader  that  as  far  as  possible  each  tetanus 
patient  must  be  isolated  in  an  extremely  quiet  room, 
where  all  causes  of  excitation  are  eliminated. 

Feeding  by  the  mouth  will  naturally  not  be  attempted 
except  in  those  cases  where  the  patient  exhibits  no 
contractures  of  the  muscles  of  the  throat,  lest  the 
so-called  food  pneumonia  should  supervene.  Conse- 
quently, the  majority  of  tetanus  patients,  as  they  suffer 
from  dysphagic  disorders,  must  be  nourished  by  means 
of  nutrient  enemas,  and  in  this  connection  enemas  of  an 
aqueous  solution  containing  7  to  10  per  cent,  of  glucose 
have  been  recommended,  or  injections  of  serum,  or 
intravenous  injections  of  a  5  or  10  per  cent,  solution  of 
sugar. 

Diuretics  are  recommended,  since  it  is  recognised 
that  the  toxins  are  eliminated  by  the  urine. 

Warm  Baths. — Tepid  or  warm  baths  constitute  a 
means  of  calming,  and  according  to  some  writers  even 
of  curing  slight  cases  of  tetanus,  and  those  of  medium 
severity.  The  beneficent  action  of  baths,  however,  has 
long  been  noted.  Two  baths  daily  are  given,  the 
temperature  being  97°  F.  to  begin  with,  increasing 
to  106°-108°  F.  The  duration  of  the  bath  should  be 
twenty  to  thirty  minutes,  or  at  most  an  hour. 

The  majority  of  patients  experience  great  relief  from 
such  baths.  During  the  bath  there  is  said  to  be  re- 
laxation of  the  trismus,  an  important  phenomenon,  since 
bathing  would  enable  the  patient  to  open  his  mouth 
more  widely,  in  order  to  absorb  food  and  medicine. 

Care  must  always  be  taken  of  the  wounds  ;  they 
should  be  protected  from  contact  with  the  water  by 
impermeable  dressings. 


TREATMENT  889 

Sedative  Treatment. — Chloroform. — Martin  and  Darre 
and  Walter  have  obtained  good  results  by  the  employ- 
ment of  inhalations  of  chloroform  in  hyper-acute 
paroxysms. 

Ether. — Intravenous  injections  of  5  to  15  c.c.  of 
ether  in  150  to  450  c.c.  of  normal  saline  solution  (Noel 
and  Souther)  cause  a  profound  sleep  of  several  hours 
after  each  injection. 

According  to  some  writers,  ether  is  said  to  destroy 
the  combination  of  the  toxin  and  the  nerve-cells. 

Potassium  bromide,  hyoscamus,  belladonna,  and 
curare,  and,  finally,  compounds  and  derivatives  of 
opium,  may  be  employed  as  adjuvants  to  other  sedative 
treatments. 

Morphia,  employed  in  subcutaneous  injections  of 
1  centigramme  four  to  five  times  per  diem,  produces 
repose,  and  causes  the  contractures  to  cease.  To  this 
may  be  added  scopolamine,  in  doses  of  '5  milligramme 
per  injection  ;  the  action  of  morphine,  associated  with 
scopolamine,  is,  according  to  certain  writers,  more 
profound  and  more  prolonged.  However,  morphia 
possesses  the  great  defect  of  causing  constipation, 
cerebral  congestion,  and  respiratory  paralysis ;  and 
the  patient  seems  more  liable  to  develop  broncho-' 
pneumonia. 

Morphia,  then,  whether  associated  with  scopolamine 
or  not,  must  be  administered  prudently.  Attempts 
are  sometimes  made  to  replace  it  by  pantopon  or 
paverin. 

Chloral. — Chloral  is  certainly  the  drug  most  em- 
ployed in  the  course  of  tetanic  paroxysms  ;  it  seems, 
moreover,  to  act  better  than  morphine. 

Chloral  was  recommended  particularly  by  Vemeuil 
as  a  symptomatic  medicament  in  tetanus.    By  pro- 


890      THE  ABNORMAL  FORMS  OF  TFTANUS 

curing  repose  and  sleep,  by  causing  a  cessation  of  the 
contractions,  it  may  maintain  the  strength  and  prolong 
life  long  enough  to  permit  the  disease  to  accomplish  its 
development  toward  recovery. 

There  is  ahnost  always  an  immediate  and  very  appar- 
ent amelioration ;  the  contractions  diminish  in  in- 
tensity and  even  cease  completely.  But  the  symptoms 
which  cease  dujring  sleep  reappear  upon  waking,  with 
much  the  same  characteristics  as  before  the  adminis- 
tration of  the  drug  (Mathieu).  As  for  definite  successes, 
they  amount,  according  to  Vemeuil,  to  two-fifths  of  the 
cases  treated ;  this  result  is  certainly  exaggerated ; 
but  it  must  be  admitted  that  chloral  increases  the 
proportion  of  recoveries. 

It  is  in  chronic  tetanus,  or  rather  in  the  slowly 
developing  form — that  is  to  say,  in  the  atypical  forms 
which  we  have  described — that  successful  results  are 
most  frequently  obtained.  We  shall  return  to  this 
point  when,  having  described  the  various  therapeutic 
methods  in  use,  we  discuss  those  which,  in  our  opinion, 
should  by  preference  be  selected  for  the  treatment  of 
the  abnormal  forms  of  tetanus. 

Chloral  may  be  continued  for  fifteen  or  twenty  days, 
and  may,  as  Poncet  remarked,  lead  gently,  through 
prolonged  slumber,  to  convalescence. 

Choral  is  usually  administered  by  the  mouth  or  the 
rectum. 

By  the  mouth,  1  gramme  of  chloral  is  given  hourly 
until  sleep  and  muscular  resolution  are  obtained.  This 
effect,  once  obtained,  it  is  maintained  without  inter- 
ruption, save  to  feed  the  patient.  He  may,  in  this  way, 
be  given  as  much  as  6,  8,  10,  12,  16,  or  20  grammes  of 
chloral  per  diem,  and  this  for  several  weeks,  until  the 
symptoms  disappear. 


TREATMENT  891 

We  may,  in  fact,  by  commencing  with  weak  doses, 
very  soon  contrive  to  exceed  the  fatal  dose  for  an  adult 
(this  varying  between  5  and  10  grammes),  but  it  must 
be  remembered  that  large  doses  may  produce  symptoms 
of  chloralism,  which  we  had  perhaps  better  describe. 
Nicaise  has  observed  toxic  effects  with  doses  of  5 
grammes  ;  hence  the  necessity  of  av^oiding  massive 
doses  of  more  than  3-  or  4  grammes. 

Chloral  poisoning  may  be  acute  or  chronic. 

In  the  acute  form,  the  phenomena  of  intoxication 
betray  themselves  in  dramatic  fashion,  consisting  of 
profound  slumber,  abolition  of  sensibility  and  the  re- 
flexes, and  swelling  of  the  face,  which  is  sometimes 
livid,  sometimes  red.  A  more  or  less  oedematous 
swelling  of  the  conjunctivae  may  also  be  noted  occasion- 
ally, sometimes  with  slight  ecchymosis,  epiphora,  and 
diplopia.  At  the  same  time  there  is  either  a  slow  or  a 
weak  and  rapid  pulse,  with  retardation  of  the  respira- 
tory movements,  a  contracted,  or  more  rarely  a  dilated 
pupil,  and  coldness  of  the  extremities.  The  hypo- 
thermia may  attain  95°  or  even  91-5°  F.,  and  erythe- 
matous eruptions  may  appear,  in  the  form  of  large  red 
patches,  more  or  less  numerous  and  extensive,  urticarial 
or  papular,  or  by  exception  purpuric. 

Death  sometimes  occurs  suddenly,  and  is  due  to  the 
stoppage  of  the  respiration,  or  more  rarely  to  paralysis 
of  the  heart.  It  may  even  happen  that  the  patient 
may  succumb  when  he  appears  to  have  recovered. 

Gubler  divides  the  syndrome  of  chloralism  into  three 
periods  : 

1.  A  phase  of  excitation,  usually  but  slightly  marked, 
and  of  short  duration. 

2.  A  period  of  hypnosis. 

3.  A  phase  of  narcosis  or  stupor. 


892      THE  ABNORMAL  FOmfS  OF  TETANUS 

Lastly,  on  awakening,  a  recurrent  delirium  may  make 
its  appearance  (Noir)  ;  but  the  chronic  form  is  that 
which  is  usually  observed,  although  this  occurs  very 
rarely.     It  may  be  mentioned  that  it  is  betrayed  by  : 

1.  Digestive  disorders. 

2.  Cutaneous  eruptions. 

3.  Disorders  of  nutrition  and  respiration. 

4.  Nervous  disorders. 

The  digestive  disorders  consist  of  vomiting. 

The  eruptions  may  assume  various  aspects. 

The  eruption  commences  with  a  diffused  redness  of 
the  skin,  presently  followed  by  a  sensation  of  respira- 
tory oppression,  with  waves  of  heat.  It  may  become 
generalised,  but  by  preference  affects  the  articulations 
on  the  side  of  extension,  and  the  portions  of  the  body 
chafed  by  the  bed.  The  patches  of  eruption,  varying 
in  size  and  form,  are  usually  slightly  salient  (Aviragnet). 

The  eruptions  may  assume  any  one  of  five  aspects : 
the  erythematous  form,  the  papular  form,  the  urticarial 
form  (Gaucher),  the  vesical  form,  and  the  petechial 
form.     These  two  last  are  the  least  usual. 

In  benign  cases,  which  are  most  usual,  the  eruption 
disappears  very  quickly  ;  it  gives  rise  to  no  febrile 
reaction  or  disagreeable  subjective  sensations.  It  dis- 
appears when  the  drug  is  discontinued,  leaving  no 
traces  behind  it ;  but  in  those  cases  in  which  it  is 
generalised  the  rash  persists  for  several  days,  and  is 
accompanied  by  fever  and  itching. 

The  eruptions  are  more  frequent  in  summer,  and  are 
often  determined  by  t^e  ingestion  of  exciting  beverages 
(coffee,  tea,  alcohol,  etc.). 

The  disorders  of  nutrition  are  betrayed  by  oedema, 
ulcerations,  petechias,  or  purpura.  The  patient  falls 
into  a  condition  of  considerable  weakness,  and  exhibits 


TREATMENT  893 

dyspnoea,    with   precordial   anguish   or   an   asphyxial 
condition. 

The  nervous  disorders  consist  of  insomnia,  with 
agitation,  or  invincible  sleep,  weakening  of  the  in- 
telligence, enfeebiement  of  the  senses,  tremors,  and 
occasionally  epileptiform  convulsions  or  paralysis. 
The  patient  usually  succumbs  while  in  a  state  of 
marasmus,  or  through  enfeebiement  and  stoppage  of 
the  heart,  or  through  paralysis. 

In  the  event  of  gastric  intolerance,  or  in  the  case  of 
fully  developed  paroxysms,  the  chloral  may  be  adminis- 
tered, as  we  have  said,  by  the  rectum.  In  this  case  the 
irritant  qualities  of  the  drug  should  be  allayed  by  the 
addition  of  mucilage,  or  120  grammes  of  milk  and  the 
yolk  of  an  egg,  making  the  enema  up  to  200  grammes. 
Usually  4  grammes  of  chloral  are  given  in  each  enema, 
and  this  is  repeated,  if  need  be,  three  to  four  times  a  day. 

Ore  and  Mayet  have  recommended  the  administration 
of  chloral  by  intravenous  injection,  solutions  of  1  in  20 
or  1  in  30  being  employed.  This  method  has  not  been 
sufficiently  tested  to  justify  its  preference  over  the 
buccal  or  rectal  administration.  However,  Mayet  re- 
ports ^  case  in  which,  after  two  intravenous  injections 
of  2  grammes  and  1  gramme,  separated  by  an  interval 
of  twenty-four  hours,  a  comatose  slumber  supervened, 
with  irregular  pulse  and  breathing,  death  occurring  three 
hours  after  the  second  injection  {Lyon  Med.,  1891). 

To  avoid  these  accidents  it  is  best,  according  to 
Mayor,  to  employ  an  isotonic  solution  of  a  maximum 
strength  of  2  per  cent.,  while  care  should  be  taken  to 
give  the  injection  extremely  slowly. 

It  must  be  remembered,  also,  that  chloral  is  counter- 
indicated  in  heart  disease,  above  all  in  cases  of  aortic 
lesions,  a  fortiori  when  there  is  degeneration  due  to 


894     THE  ABNORMAL  FORMS  OF  TETANUS 

myocarditis  (in  alcoliolics  principally).  Chloral  is  a 
cardiac  poison,  and  weak  doses  must  therefore  always 
be  employed  in  heart  diseases  or  alcoholism.  We  have 
seen  that  massive  doses  should  be  avoided  even  in  the 
case  of  adult  patients  free  from  any  organic  defect.  If 
these  conditions  be  scrupulously  fulfilled  chloral  may, 
according  to  some  writers,  be  sufficient  alone.  In 
certain  rare  and  individual  cases  it  may  lead  to 
recovery. 

Sulphate  of  Magnesium  ^ 

The  effect  of  intra-cerebral  injections  of  magnesium 
sulphate  was  studied  about  nineteen  years  ago  by 
S.  J.  Meltzer.  He  found  that  after  an  intra-cerebral 
injection  of  a  few  drops  of  a  5  per  cent,  magnesium 
sulphate  solution,  the  animal  turned  on  one  side  and 
remained  for  hours  in  a  stuporous  condition.  As  a 
result  of  investigations  extending  over  the  last  twelve 
years  with  Dr  John  Auer,  Meltzer  considers  that  the 
dominant  action  of  magnesium  salts  on  the  living  body, 
no  matter  by  which  way  it  is  administered,  consists  in 
depression  or  inhibition  of  nervous  activity.  Con- 
sciousness is  the  first  thing  which  is  completely 
abolished.  The  unconsciousness  is,  as  a  rule,  accom- 
panied by  a  great  muscular  relaxation,  while  all  the 
reflexes  may  still  remain  nearly  unaffected.  With  a 
larger  dose  of  magnesium  the  reflexes,  too,  begin  to 
disappear,    and   with   a    still   further   increase   of  the 

'  A  somewhat  lengthy  excursus  on  the  physiological  action  of  mag- 
nesium salts  has  been  omitted,  and  a  summary  of  the  views  of  Meltzer, 
to  whom  we  are  almost  *^ntirely  indebted  for  our  knowledge  of  tlie 
potion  ot  magnesium,  is  inserted  in  its  place.  (Vide  "Inhibitory 
Properties  of  Magnesium  Sulphate  and  their  Therapeutic  Application 
in  Tetanus,"  S.  J.  Meltzer,  Jounuil  American  Medical  Asaociation, 
vol.  Ixvi.,  No.  13,  March  25,  1916,  pp.  931-1*84.— Ed.) 


TREATMENT  895 

magnesium  dose  the  motor  nerve  endings  become 
paralysed — a  curare-like  action,  which  is  accompanied, 
of  course,  by  a  simultaneous  profound  central  action. 

Chemically,  calcium  and  magnesium  are  closely 
related  substances.  Biologically,  however,  they  are 
strikingly  antagonistic  to  one  another.  Auer  and 
Meltzer  found  that  an  animal  which  may  have  been 
completely  paralysed  by  a  magnesium  salt  can  be 
restored  within  a  fraction  of  a  minute  by  an  intra 
venous  injection  of  a  calcium  salt.  It  must  be  added, 
however,  that  this  applies  essentially  to  conditions  in 
which  the  animal  was  exposed  to  the  effect  of  magnesium 
for  a  comparatively  short  time.  When  the  animal  is 
saturated  with  magnesium  for  a  longer  period,  the 
antagonistic  action  of  calcium  is  less  evident  and  is 
even  not  without  some  danger. 

As-  is  well  known,  the  various  neurons  are  not  con- 
nected by  direct  continuity  but  by  mere  contact. 
That  place  of  contact  is  termed  by  Sherrington 
''synaptic  membrane."  The  contact  between  motor 
nerve  and  muscle  is  also  not  of  a  very  solid  character, 
and  is  termed  by  some  also  synaptic  membrane.  It  is 
assumed  that  the  magnesium  solution  contained  in  the 
lymph  bathing  the  synaptic  membrane  enters  with 
ease  into  these  spaces  and  interrupts  the  passage  of 
nervous,  afferent  impulses  from  one  organ  to  the  other, 
especially  of  such  impulses  for  which  there  is  a  less 
readily  prepared  path  for  transmission  than  the  paths 
existing  for  normal  active  reflexes. 

What  is  said  of  magnesium  applies  also  to  calcium. 
When  it  is  present  in  the  lymph  in  a  quantity  larger 
than  normal,  it  enters  readily  into  the  synaptic  mem- 
brane and  displaces  or  neutralises  the  obstructing  or 
inhibiting  magnesium. 


896       THE  ABNORMAL  FORMS  OF  TETANUS 

The  effect  of  magnesium  salts  was  investigated 
extensively  on  animals  and  in  a  comparatively  con- 
siderable degree  also  on  human  beings  by  intravenous, 
intraspinal,  intramuscular,  and  subcutaneous  injec- 
tions. In  all  modes  of  administration  the  effect  is,  as 
stated  before,  unmistakably  depressing  in  character. 
In  intravenous  application  the  effect  is  rapid,  and  when 
so  used  it  must  be  guarded  against  possible  harmful 
accidents.  The  inhibitory  effect  of  an  intraspinal  in- 
jection sets  in  fairly  early,  and  may  last  even  longer 
than  twenty-four  hours.  Intramuscular  injections 
have  a  fairly  rapid  effect,  but  its  duration  is  com- 
paratively short.  Subcutaneous  injections  act  slowly 
but  have  a  cumulative  effect.  Meltzer  asserts  that 
no  other  remedy  is  capable  of  relieving  the  furious 
symptoms  of  acute  tetanus  to  such  a  satisfactory  degree 
as  do  the  injections  of  magnesium  sulphate.  On  the 
basis  of  the  above-mentioned  theory  he  states  that  we  \ 
may  expect  from  the  use  of  magnesium  sulphate  per- 
haps even  more  than  a  symptomatic  action  ;  it  is 
possible  that  the  magnesium  salts,  accumulated  in  the 
lymph,  enter  into  the  synaptic  membrane  between  two 
neurons,  and  thus  prevent  the  wandering  of  the  tetanus 
toxin  through  higher  neurons  and  into  the  correspond- 
ing nerve-cells. 

influence  of  Magnesium  upon  the  Temperature  of  the 
Body. — Experimentally,  in  the  rabbit,  a  considerable 
lowering  of  the  temperature  has  been  noted  as  produced 
by  sulphate  of  magnesium.  This  fall  of  temperature 
is  not  a  direct  consequence  of  the  narcosis.  It  is  a 
parallel  phenomenon.  The  magnesium,  doubtless,  acts 
directly  upon  the  centre  regulating  the  production  of 
heat.  This  fall  of  temperature,  moreover,  is  noted  after 
doses  of  magnesium  whicli  do  not  produce  the  slightest 


TREATMENT  89r 

symptoms  of  paralysis,  still  less  of  narcosis.  A  very 
careful  examination  of  the  thermal  curve  shows  that  a 
very  marked  paralleUsm  exists  between  the  temperature 
and  the  indications  of  magnesium  poisoning.  The  fall 
of  temperature  is  proportionate  to  the  rapidity  of  on- 
set of  the  symptoms  of  paralysis  and  narcosis.  With  a 
little  practice  one  may,  from  the  extent  and  the  rapidity 
of  the  thermic  fall,  establish  a  prognosis  of  the  gravity 
of  the  magnesium  poisoning. 

When  narcosis  sets  in,  and  also,  almost  always,  when 
the  first  symptoms  of  paralysis  appear,  these  phenomena 
are  immediately  announced  by  a  sudden  and  violent 
drop  in  the  thermic  curve.  In  the  treatment  of  tetanus, 
therefore,  we  must  employ  sulphate  of  magnesium  with 
prudence,  and  must  systematically  take  the  patient's 
temperature  ;  the  indications  with  which  it  provides  us 
are  important  guides  in  the  matter  of  regulating  the 
dose  and  avoiding  accidents. 

Action  of  Magnesium  upon  the  Circulation.— ~lt  has 
long  been  kno\\Ti  that  the  sulphate  and  other  salts  of 
magnesium  are  cardiac  poisons.  Experimentally,  it 
has  been  proved  that  magnesiimi  diminishes  the  blood- 
pressure  without  decreasing  the  frequency  of  the  heart- 
beats ;  and  that  the  disorders  of  the  circulation  pro- 
duced by  magnesium  cannot  in  any  way  be  ameliorated 
by  calcium.  Thus,  if  we  almost  kill  an  animal  with  too 
large  a  dose  of  magnesium,  the  respiration  disappears 
and  the  movements  of  the  heart  become  less  frequent, 
but  an  intravenous  injection  of  calcium  re-establishes 
the  respiration,  while  the  heart  recovers  only  as  the 
oxygenation  of  the  system  becomes  improved. 

Anv  therapeutic  action  of  magnesium  is  accompanied 
by  enfeeblement  of  the  circulation.  In  the  magnesium 
treatment,  therefore,  we  must  pay  all  the  more  attention 


898        THE  ABNORMAL  FORMS  OF  TETANUS 

to  the  state  of  the  respiration,  inasmuch  as  calcium, 
used  as  an  antidote,  acts  only  on  the  respiration,  and 
not  at  all  on  the  enfeebled  circulation. 

Mode  of  Adriiinistration  and  Dose, — Experiments 
upon  the  rabbit  have  enabled  us  to  discover  the  mechan- 
ism of  the  therapeutic  action  of  magnesium. 

Sulphate  of  magnesium  injected  under  the  skin  is 
quickly  eliminated. 

Its  action  is  in  proportion  to  its  degree  of  concen- 
tration. 

Experiment  has  also  proved  that  the  rapidity  with 
which  magnesium  injected  under  the  skin  is  absorbed  is 
very  inconstant,  above  all  when  highly  concentrated 
solutions  have  to  be  employed. 

From  these  investigations  it  results  that  the  sub- 
cutaneous injection,  at  one  time,  of  large  doses  of 
sulphate  of  magnesium  is,  in  the  treatment  of  tetanus, 
an  insufficient  procedure.  It  might  be  advantageous 
in  serious  cases  of  traumatic  tetanus,  the  duration  of 
which  is  short.  In  less  severe  cases,  with  a  chronic 
tendency,  it  constitutes  only  an  indication  of  symptom- 
atic treatment. 

Intravenous  Injections  of  Sulphate  of  Magnesium. — 
To  obtain  a  rapid  and  lasting  effect,  intravenous  in- 
jections should  be  employed. 

It  is  possible,  with  a  3  per  cent,  solution  of  sulphate 
of  magnesium  in  an  isotonic  solution,  to  obtain  an  action 
of  the  magnesium  upon  the  terminals  of  the  motor 
nerves  which  will  last  for  some  hours ;  an  action 
which  is  in  proportion  to  th^  rapidity  of  injection.  By 
this  means  wcmay  obtain  a  condition  in  which  the 
magnesium,  injected  into  the  veins  with  a  certain 
rapidity,  is  eliminated  by  the  kidneys  with  the  same 
rapidity.     We   may   thus,   with   a   given   strength  of 


TREATMENT  899 

solution,  and  according  to  the  rate  of  injection,  affect 
all  the  peripheral  nerves,  while  leaving  the  patient  with 
sufficient  powers  of  respiration,  and  without  producing 
a  notable  diminution  of  the  blood-pressure.  The  action 
of  magnesium  injected  into  the  veins  may  be  quickly 
arrested  ;  it  is  enough  to  remark  that  experimentally, 
in  animal  subjects,  its  action  may  be  suddenly  destroyed 
by  injecting,  into  a  vein,  2  c.c.  of  a  5  per  cent,  solution 
of  chloride  of  calcium.  The  reaction  produced  by 
calcium  is  of  short  duration. 

In  the  case  of  the  human  subject,  therefore,  we  must 
pay  great  attention  to  the  rate  of  injection,  and  none 
but  chemically  pure  sulphate  of  magnesium  must  be 
employed.  The  commercial  salt  contains  more  or 
less  water.  (Chemically  pure  sulphate  of  magnesium 
crystallises  with  about  seven  molecules  of  water.) 

Simultaneously  with  its  paralysing  action,  sulphate 
of  magnesium  in  solution  has  a  very  marked  diuretic 
action.  The  respiration  must  be  watched  during  in- 
jection, and  the  injection  must  be  discontinued  if  the 
respiratory  movements  become  too  feeble,  or  if  the 
patient  exhibits  cyanosis.  In  the  event  of  danger  an. 
intravenous  injection  of  a  5  per  cent,  solution  of  calcium 
chloride  should  be  slowly  administered.  This  injec- 
tion will  not  prevent  the  action  of  subsequent  doses  of 
magnesium. 

Intrarachidian  Injection. — This  method,  recommended 
by  Kocher,  is  not  based  on  any  specific  action.  In 
man  this  method  is  difficult,  and  it  takes  a  very  long 
time  to  inject  a  single  dose.  The  injection  causes  a 
paralysis  of  the  intrarachidian  nerve- trunks.  The 
action  is  more  lasting,  but  the  method  possesses  the 
drawbacks  that  we  do  not  know  the  dosage  of  the  in- 
jection, and  the  exmaination  of  the  respiration  during 


900        THE  ABNORMAL  FORMS  OF  TETANUS 

injection  is  difficult.    Lastly,  the  action  of  calcium  as  an 
antidote  has  not  been  verified  ;  it  seems  hardly  probable. 
From  experimental  researches  it  follows  that : 

1.  The  subcutaneous  or  even  intramuscular  injection 
of  a  highly  concentrated  solution  of  sulphate  of 
magnesium  is  the  worst  means  of  introducing  the 
substance  into  the  system,  since  we  are  not  certain  by 
such  means  of  obtaining  the  greatest  rapidity  of 
absorption.  The  paralysing  action  wUl  be  of  brief 
duration,  consequently  the  injection  will  produce 
amelioration  only  in  the  slighter  forms  of  tetanus. 

2.  The  intravenous  injection  of  sulphate  of  magnesium 
has,  on  the  contra^}^  the  advantage  of  exerting  a  last- 
ing action  on  the  nerves,  and  enables  us  to  maintain 
this  action  for  many  hours.  It  might,  therefore,  be 
employed  when  the  patient  is  in  danger  of  death  from 
asphyxia  resulting  from  cramps.  It  gives  the  patient 
time  to  recover  under  the  natural  treatment  of  tetanus 
— ^that  is,  treatment  by  antitoxin.  Death  from  cardiac 
disorders  in  tetanus  patients  results,  as  a  matter  of  fact, 
from  the  intense  muscular  labour  provoked  by  the 
cramps. 

3.  Treatment  by  intralumbar  injections  gives  results 
which  are  longer  in  duration,  and*  more  in  proportion 
to  the  dose,  than  those  obtained  by  subcutaneous 
injection.  In  a  serious  case  of  tetanus  intralumbar 
injection  is  very  difficult,  and  it  cannot  readily  be  often 
repeated.  Moreover,  if  accidents  occur  as  the  result  of 
an  overdose  their  treatment  is  problematical. 

To  refer  no  further  to  the  data  derived  from  experi- 
ment, which  have  thrown  some  light  upon  the  treatment 
pf  tetanus  by  sulphate  of  magnesium,  let  us  now  con- 
sider the  clinical  results  of  this  treatment. 

Two  writers  have  succeeded,  by  means  of  the  mag- 


TREATMENT  901 

nesium  treatment,  under  conditions  which  endangered 
hfe,  in  rendering  deglutition  and  respiration  possible, 
in  averting  the  danger  of  death  during  the  painful 
paroxysms,  in  facilitating  alimentation,  and  in  diminish- 
ing the  number  of  paroxysms.  In  one  case  the  number 
of  paroxysms  occurring  in  a  given  time  was  thirty- 
three  ;   this  was  reduced  to  fourteen. 

This  treatment  enables  the  patient  to  raise  his  head 
and  open  his  mouth,  while  it  dispels  the  dyspnoea. 
According  to  the  same  writers,  sulphate  of  magnesium 
injected  subcutaneously  is  an  energetic  remedy, 
diminishing  the  tetanic  hyperexcitability  and  the 
violence  and  frequency  of  the  painful  paroxysms.  It 
is  especially  useful  in  the  spasms  of  deglutition  and 
respiration  which  endanger  the  patient's  life.  It 
averts  extreme  weakness  and  asphyxia  ;  it  diminishes 
the  number  and  intensity  of  the  cramps.  It  should  not 
be  employed  in  intrarachidian  injections,  the  duration 
of  which  is  limited,  unless  these  are  clinically  necessary. 
As  for  technical  details,  a  20  to  25  per  cent,  solution 
should  be  employed  for  children  and  a  40  to  50  per 
cent,  solution  for  adults.  Additional  supra-aponeurotic 
injections  should  be  given,  the  injection  being  com- 
menced with  a  little  saline  water. 

Kocher  advises  the  employment  of  a  10  to  15  per  cent, 
solution.  He  injects  5  c.c.  of  this  by  intrarachidian, 
intravenous,  or  intramuscular  injection,  and  according 
to  this  writer  intrarachidian  and  intravenous  injections 
are  more  dangerous  than  subcutaneous  or  intramuscular 
injections.  The  results  have  been  encouraging. 
Kocher  claims  to  have  obtained,  by  this  treatment,  six 
recoveries  in  seven  cases  of  tetanus.  Other  surgeons, 
in  particular  Powers,  Miller,  Fox,  and  Johnson,  have 
reported  cases  of  recovery. 


902       THE  ABNORMAL  FORMS  OF  TETANUS 

Smithson,  treating  two  cases  of  tetanus  by  this 
method,  had  one  death  due  to  paralysis  of  respiration. 
In  some  recent  statistics  (1914)  a  writer  reports,  as  a 
result  of  bibliographical  research,  that  twenty-seven 
cases  of  tetanus  thus  treated  yielded  only  nine  deaths. 

How  should  sulphate  of  magnesium  be  employed, 
and  in  what  doses  ? 

Subcutaneous  Injection, — By  this  method  10  to  15  c.c. 
of  a  25  per  cent,  solution  of  sulphate  of  magnesium  may 
be  injected  two  to  three  times  a  day.  This  method  is 
said  in  particular  to  have  yielded  excellent  results  in 
Monod's  hands,  as  recorded  in  the  observation  of  atypic 
tetanus  already  cited. 

It  should  be  remembered  that  very  large  doses  may 
be  given — as  much  as  100  c.c.  even — and  by  employing 
a  40  per  cent,  solution  as  much  as  60,  80,  or  100  c.c.  has- 
been  injected  during  the  twenty-four  hours  in  extremely 
serious  cases. 

Subcutaneous  injection  of  sulphate  of  magnesium 
is  really  painful,  and  it  is  often  necessary  to  give 
an  injection  of  morphia  before  administering  the 
magnesium. 

The  effect  of  the  magnesium  usually  becomes  visible 
after  the  lapse  of  half-an-hour,  and  lasts  five  or  six  hours. 
Under  certain  conditions  the  effect  may  last  longer. 
After  the  injection  the  patient  falls  into  a  light  sleep  ; 
the  contractures  and  muscular  cramps  are  greatly 
diminished.  In  slight  cases  and  cases  of  medium 
severity  these  symptoms  may  even  disappear  com- 
pletely. 

Sulphate  of  magnesium  injected  under  the  skin  has, 
then,  a  manifest  sedative  action,  which  establishes 
itself  slowly  and  lasts  for  some  time. 

A  great  drawback  is  the  great  pain  caused  by  sub- 


TREATMENT  903 

cutaneous  injection.  This  pain  persists  long  after  the  in- 
jection, and  an  abscess  may  often  be  observed  to  develop 
at  the  point  of  injection,  which,  however,  as  a  rule, 
quickly  disperses  after  incision.  This  abscess  is  caused 
by  a  slight  haemorrhage  which  invades  the  cellular 
tissue  and  the  muscles  around  the  point  of  injection. 

Pain,  and  occasionally  necrosis,  are  two  complica- 
tions which  have  caused  the  majority  of  physicians  to 
abandon  the  employment  of  subcutaneous  injections 
in  the  symptomatic  treatment  of  tetanus  by  sulphate 
of  magnesium. 

However,  the  statistics  are  encouraging ;  certain 
writers  speak  of  50  per  cent,  of  recoveries  ;  others  are 
less  optimistic  ;  one  foreign  writer  in  particular  is  said 
to  have  obtained  five  recoveries  and  twelve  deaths  by 
this  method. 

Intrarachidian  Injection. — By  this  method  2  c.c.  of 
a  25  per  cent,  solution  may  be  injected  without  acci- 
dents. 

Griffon  and  Lian  employ  a  solution  of  this  strength, 
injecting  1  c.c.  for  every  25  lb.  of  the  patient's  weight. 

Ramon  and  Dury  inject  5  c.c.  of  a  25  per  cent,  solu- 
tion. Kocher  prefers  10  c.c.  of  a  10  per  cent,  solution. 
Other  writers  inject  6  to  8  c.c.  of  a  similar  solution.  In 
most  cases  the  sulphate  of  magnesium  is  observed  to  act 
effectually  upon  the  contractures,  but  as  Kocher  has 
stated  ?(who  cured  four  patients  out  of  five  by  this 
method),  a  sudden  arrest  of  respiration  may  supervene. 
In  one  case  this  writer  was  even  forced  to  resort  to 
tracheotomy  and  artificial  respiration. 

Other  writers,  to  obviate  this  danger,  have  advised 
the  intravenous  injection  of  chloride  of  calcium,  or  the 
lavage  of  the  lumbar  sac  with  a  saline  solution.  It  is 
also  said  that  the  respiratory  disorders  are  amended  by 


904       THE  ABNORMAL  FORMS  OF  TETANUS 

withdrawing  cerebro-spinal  fluid  and  an  injection  of  1 
milligramme  of  atropine. 

It  must  also  be  remembered  that  intrarachidian  in- 
jections of  sulphate  of  magnesium  may  give  rise  to  a 
sudden  rise  of  temperature,  cephalea,  erythema,  zona, 
retention  of  urine,  paralysis  of  the  lower  limbs,  coma, 
and  sometimes  an  intense  meningeal  reaction.  All 
these  inconveniences  are  perhaps  due  to  impurities  in 
the  sulphate. 

According  to  Bienfait  and  Leroy,  who  have  published 
three  observations,  this  method  enables  the  physician 
to  gain  time,  and  the  employment  of  an  isotonic  solution 
should  obviate  accidents. 

The  observations  published  by  Sicard  and  Drevet 
and  Debre  clearly  demonstrate  the  favourable  influence 
of  sulphate  of  magnesium  on  the  painful  paroxysms, 
and  afford  proof  that  sulphate  of  magnesium  must 
be  regarded  purely  as  a  symptomatic  remedy,  since 
death  has  supervened  despite  the  cessation  of  the 
contractures. 

Intravenous  Injection. — In  this  method  a  3  per  cent, 
solution  is  usually  employed.  There  are  two  difficulties 
to  be  avoided : 

1.  The  solution  should  not  be  too  dilute,  or  the 
circulartion  would  be  needlessly  disturbed. 

2.  Neither  must  the  solution  be  too  concentrated,  or 
it  would  cause  osmotic  disorders  in  the  blood  and 
tissues. 

Intravenous  injections  of  sulphate  of  magnesium 
have  not  been  very  largely  employed  in  France.  It 
does  not  seem  that  intravenous  injection  offers  any 
advantages  over  intrarachidian  or  subcutaneous  in- 
jection. 

We  mention  it  only  for  the  sake  of  completeness  in 


TREATMENT  905 

this  summar}^  of  the  different  treatments  at  present 
employed  in  combating  the  tetanic  infection. 

Symptomatic  Surgical  Treatment. — In  the  event  of 
the  grave  asphyxial  phenomena  which  result  from  the 
contractures  of  the  respiratory  muscles,  certain  writers 
have  advised  tracheotomy,  and  others  phrenicotomy. 

Tracheotomy.— One  writer,  in  two  cases  of  severe 
tetanus,  with  imminent  danger  of  death  as  a  result  of 
cramps  of  the  respiratory  muscles,  performed  trache- 
otomy. The  improvement  in  the  respiration  was  sur- 
prising ;  the  cyanosis  disappeared  almost  entirely 
during  all  the  paroxysms  subsequent  to  the  operation. 
It  seems  as  though  the  occasional  sudden  death  of 
tetanus  patients  in  these  cases  is  due,  not  to  the  cramps 
of  the  diaphragm  and  other  muscles  of  the  thorax,  but 
rather  to  the  trismus  and  the  contracture  of  the  muscles 
of  the  tongue,  pharynx,  and  larynx. 

Bilateral  Phrenicotomy. — Jehn,  of  Zurich,  has  advised 
bilateral  section  of  the  phrenic  nerves  in  the  dangerous 
contractures  of  the  respiratory  muscles  provoked  by 
tetanus. 

In  these  serious  cases  the  diaphragm  remains  con- 
vulsively contracted  in  the  position  of  maximum  in- 
spiration. The  intercostal  muscles  and  those  of  the 
neck  and  thorax  are  themselves  contractured.  They 
accordingly  hold  the  thoracic  cage  unmobilised  in  the 
position  of  forced  inspiration.  Active  or  reflex  move- 
ments of  the  diaphragm  and  the  ribs  are  consequently 
impossible,  hence  the  impossibility  of  changing  the 
volume  of  the  pulmonary  apparatus,  the  cessation  of 
respiratory  exchanges,  and  the  imminence  of  asphyxia. 

These  mechanical  reasons  are  a  complete  obstacle  to 
artificial  respiration.  The  thorax  has  lost  all  .power  of 
movement ;     the   contractured   diaphragm  bounds   it 


906      THE  ABNORMAL  FORMS  OF  TETANUS 

below,  while  the  osseous  portion  above  the  diaphragm 
becomes  a  sort  of  box,  with  rigid  walls,  imprisoning 
the  lungs. 

In  these  cases  narcotics  act  too  slowly.  General 
anaesthesia  cannot  be  attempted.  Artificial  respira- 
tion fails  absolutely  in  these  cases  of  tetanic  cramps. 
As  for  sulphate  of  magnesium,  the  dose  is  too  uncertain, 
and  its  action  is  transitory.  Lastly,  a  simple  or  double 
pneumothorax,  which  has  the  advantage  of  liberating 
the  lung,  permits  of  the  re-establishment  of  the  intra - 
pulmonary  exchanges  by  artificial  inspiration  and 
expiration,  but  artificial  respiration  must  be  con- 
tinued until  the  cessation  of  the  paroxysm,  and  the 
grievous  consequences  of  such  respiration  are  well 
known. 

Phrenicotomy  completely  paralyses  the  muscles  of 
respiration,  and  the  augmentation  of  the  intrabronchial 
pressure,  followed  by  a  diminution  of  this  pressure, 
gives  rise  to  pulmonary  movements. 

Experimentally  we  know  that  the  bilateral  section 
of  the  phrenic  nerve"  in  an  animal  involves  no  disorders. 
Basing  his  argument  on  this  fact,  Jehn,  in  a  case  of 
tetanus  with  dangerous  respiratory  cramps,  proposed 
bilateral  phrenicotomy.  Artificial  respiration  was  found 
to  be  possible  after  the  operation,  and  he  was  thus 
able  to  calm  thirty-five  grave  attacks  of  asphyxia.  But 
this  paralysis  of  the  diaphragm  must  not  be  resorted  to 
except  to  permit  of  artificial  respiration. 

From  Jehn's  observation  it  results  that  the  bilateral 
section  of  the  phrenic  nerves  involves  no  danger, 
cardiac  or  other,  and  this  paralysis  of  the  diaphragm 
does  not  prevent  expectoration.  There  is  one  fact 
which  must  be  remembered — namely,  that  .Jehn'« 
patient  was  able  to  draw  in  only  a  small  quantity  of  air 


TREATMENT  907 

at  each  inspiration  ;  but  clinical  observation  proves 
that  the  respiratory  exchanges  may  be  very  greatly 
diminished  without  the  production  of  marked  organic 
disturbances.  The  organism,  as  a  general  thing,  adapts 
itself  to  all  such  modifications. 

Still,  if  we  take  into  account  the  frequency  of  broncho- 
pneumonia in  cases  of  tetanus  it  seems  that  we  should 
have  recourse  to  phrenicotomy  only  in  desperate  cases 
with  grave  and  acute  asphyxia. 

Conclusions 

Mioced  Treatment.- — Now  that  we  have  described  the 
various  therapeutic  methods  successively  recommended 
in  tetanus,  whatever  its  clinical  development,  we  propose 
to  conclude  this  chapter  on  the  treatment  of  atypical 
tetanus  by  summarising  the  procedure  which  appears 
to  us  the  best  and  wisest  to  follow  when  the  clinician 
is  confronted  by  an  abnormal  form  of  tetanus. 

It  is  enough  to  recall  the  pathogenesis  and  develop- 
ment of  the  tetanic  infection.  In  the  infected  wound 
the  bacillus  of  Nicolaier,  favoured  by  saprogenous 
associations,  secretes  its  toxin,  which  may,  as  the  in- 
vestigations of  A.  Marie  have  established,  follow  the 
course  of  the  nerves  until  it  reaches  the  medullary  and 
bulbar  centres,  where  it  fixes  itself,  or  may  be  trans- 
ported by  the  circulation. 

From  this  moment  the  infection  is  completed,  and, 
as  Sahli  has  clearly  demonstrated,  the  nervous  cells 
modified  by  the  toxin  react  for  a  certain  time  on  their 
own  account — thus  creating  the  tetanic  syndrome. 
So  true  is  this  that  the  cellular  reactions,  with  the  con- 
tractures which  are  their  symptoms,  may  continue  to 
manifest  tliemselves,  may  develop,  and  may  determine 


908       THE  ABNORMAL  FORMS  OF  TETANUS 

a  fatal  result  when  the  toxins  liave  been  eliminated  from 
the  system. 

In  the  development  of  tetanus,  then,  we  may  recog- 
nise three  phases  : 

1.  The  bacillus  secretes  its  toxins  ;  this  is  the  phase 
of  infection. 

2.  The  toxins  invade  and  fix  themselves  upon  the 
nervous  cells  ;  this  is  the  period  of  intoxication. 

3.  The  intoxicated  nervous  cells  cause  contracture  ; 
this  is  the  phase  of  cellular  reaction. 

As  Etienne  has  justly  remarked,  there  is  everj^  reason 
for  believing  that  these  different  phases  overlap  in  the 
clinical  picture.  It  is  possible  that  those  nervous  cells 
which  are  attacked  by  the  toxin  may  be  disintoxicated 
by  antitetanic  serum,  at  all  events  when  their  progres- 
sive impregnation  has  not  given  rise  to  irremediable 
lesions.  They  may  become  disintoxicated  spontane- 
ously, for  contractures  may  yield  where  serotherapy 
has  not  been  employed  ;  but  the  serum  possibly  exerts 
a  disintoxicating  action  upon  them.  Such  a  disintoxi- 
cation would  occur  in  successive  stages,  and,  as  a  rule, 
those  cells  which  are  first  reached  b}^  the  toxin — that  is, 
those  whose  impregnation  is  elective — w^ould  be  the  last 
to  become  disintoxicated.  Thus  the  trismus,  which  is 
the  first  clinical  manifestation  in  the  classic  or  cephalic 
forms  of  tetanus,  is  often  the  last  tetanic  sjnuptom  to 
}deld  to  serotherapy. 

On  the  whole,  tetanus  may  be  regarded  as  an  in- 
fectious malady,  as  an  intoxication,  and  finally  a 
nervous  malady  ;  the  necessity  of  a  mixed  or  com- 
bined treatment  will  accordingly  be  perceived. 

A  special  treatment  corresponds  to  each  of  the  three 
phases  of  tetanic  development :  to  the  first  phase 
corresponds  the  suppression  of  the  infected  centre  ;   to 


TREATMENT  909 

the  second,  serotherapy  ;  to  the  third,  the  symptomatic 
treatment. 

By  combining  these  three  treatments  we  neutralise 
the  invading  toxin,  the  object  of  the  symptomatic  anti- 
spasmodic treatment  being  to  Hmit  the  reaction  of  the 
intoxicated  cell  upon  excitation,  while  the  local  treat- 
ment of  the  wound  aims  at  suppressing  the  spot  where 
the  toxins  are  produced. 

It  will  be  understood  from  this  that  an  isolated 
treatment  of  incontestable  value,  such  as  serotherapy, 
is  not  in  itself  sufficient. 

In  dealing  with  a  case  of  atypical  tetanus  we  must 
therefore  : 

1.  Disinfect  the  wound,  where  the  toxins  are  pro- 
duced. In  this  connection  we  refer  the  reader  to  the 
local  treatment  of  tetanus,  which  we  have  already 
discussed. 

2.  Although  localised,  the  atypical  forms  must  not 
be  neglected.  Despite  their  benign  development  and 
occasionally  prolonged  incubation,  they  must,  from  the 
first  symptoms,  be  treated  as  energetically  and  in- 
tensively as  the  normal  forms.  Finally,  it  must  be 
remembered  that  these  are  the  cases  which  are  most 
susceptible  of  cure  by  massive  doses  of  serum.  But 
here  we  had  best  repeat  that  there  is  no  excuse  for 
exaggerating  intensive  doses,  for  they  do  not  indefinitely 
increase  the  curative  effect  of  the  serum. 

Moreover,  the  quantity  of  serum  injected  is  by  no 
means  a  negligible  factor  in  the  production  of  anaphy- 
lactic accidents,  and  if  they  may  break  out  after  small 
injections,  they  are  far  more  liable  to  occur  after  heavy 
doses.  Doses  of  100  c.c.  seem  to  us  excessive,  and  by 
injecting  a  first  dose  of  50  c.c.  and  progressively  dim- 
inishing it  by  10   c.c.  each  day  we  doubtless  obtain 


910       THE  ABNORMAL  FORMS  OF  TETANUS 

equally  good  results.  By  this  method,  moreover, 
Barnsby  and  Mercier  have  obtained  excellent  results. 

We  ought  also  to  mention,  although  we  do  not  share 
his  opinion,  that  Fricker  recommends,  in  the  atypical 
forms  of  tetanus,  small  injections  of  antitetanic  serum 
(5  c.c.)  repeated  daily.  According  to  this  writer  this 
is  the  treatment  which  best  succeeds  in  these  partial 
cases. 

Subcutaneous  injections  alone  must  be  employed, 
and  even  so  the  to-day  well-known  anti-anaphylactic 
precautions  should  be  taken  in  order  to  avoid  the 
appearance  of  serious  accidents. 

Heavy  doses  will  never  be  administered  straightway 
to  patients  who  have  received  a  preventive  injection 
or  injections.  One  should  commence  by  injecting  a 
small  dose  (-5  c.c.  to  1  c.c),  and  a  few  hours  later  the 
rest  of  the  dose.  The  injection  should  be  strictly 
subcutaneous  and  not  intramuscular,  the  latter  being 
more  anaphylactic.  In  no  case,  however,  must  the  fear 
of  anaphylactic  accidents  prevent  the  employment  of  a 
treatment  which  may  be  efficacious  ;  all  that  is  needful 
is  to  give  none  but  subcutaneous  injections  and  reason- 
able curative  doses. 

3.  Lastly,  with  the  serotherapic  treatment  we  must 
associate  a  symptomatic  treatment  which  is  all  the 
more  to  be  recommended  in  the  partial  atypical  forms 
of  tetanus. 

Chloral,  in  doses  of  8  to  10  grammes  ;  carbolic  acid, 
in  doses  of  -80  to  1  gramme  ;  subcutaneous  injections 
of  sulphate  of  magnesium  (Monod) — these  may  exert  a 
favourable  and  curative  effect.  It  has  even  been 
claimed  that  symptomatic  treatment  has  by  itself  led 
to  recovery  in  certain  partial  forms  of  tetanus.  It 
certainly  seems  that  in  these  cases  there  was  rather  a 


TREATMENT  911 

question  of  painful  contractures  in  a  wounded  subject 
than  of  veritable  localised  tetanus.  Bazy  and  Vaillard 
have  justly  remarked  that  in  many  cases  bacteriological 
examination  and  experimental  inoculation  have  failed 
to  confirm  the  tetanic  nature  of  the  affection.  One 
supposes,  therefore,  that  a  symptomatic  therapeutics 
may  have  sufficed  to  work  a  cure  in  cases  to  which  the 
name  of  tetanus  has  been  wrongly  applied. 

Following  these  hints,  despite  the  too  sweeping 
assertion  of  Charles  Laurent,  the  clinician  may  ensure 
for  his  patient  the  conditions  most  likely  to  lead  to 
recovery.  By  the  combination  of  the  various  thera- 
peutic methods  we  believe  that  the  mortality  in  cases 
of  atypical  tetanus  can  be  still  further  reduced.  How- 
ever this  may  be,  localised  tetanus  remains  a  serious 
complication  of  the  wounds  received  in  time  of  war,  so 
that  it  is  impossible  to  insist  too  strongly  on  the  neces- 
sity of  prophylactic  treatment. 

We  can,  without  a  doubt,  diminish  the  number  of 
cases  of  tetanus,  whatever  the  variety : 

1.  By  mechanically  cleansing,  and  making  anti- 
septic, all  wounds  contaminated  by  the  soil  or  by 
suspect  foreign  bodies,  immediately,  or  as  soon  as 
possible,  after  the  infliction  of  the  wound. 

2.  By  injecting  antitetanic  serum  preventively  in  all 
cases  of  septic  wounds.  A  first  injection  should  be 
given  immediately  after  the  traumatism,  and  a  second 
eight  days  later.  If  tetanus  is  exceptional  after  a  first 
injection,  it  is  excessively  rare  after  a  second.  We 
know,  indeed,  that  after  these  preventive  injections 
immunisation  is  not  always  perfect.  Very  exception- 
ally it  is  insufficient,  permitting  of  an  eventual  out- 
break of  tetanus.  But  the  residual  immunisation  has 
at  least  this  advantage,  in  tliese  very  rare  cases,  of 


912       TEE  ABNORMAL  FORMS  OF  TETANUS 

localising  the  infection;   and  the  malady  being  local- 
ised, it  develops  with  a  benign  prognosis. 

3.  A  fresh  injection  should  also  be  given  before  any- 
subsequent  surgical  intervention,  and  then  the  wounded 
man,  in  the  vast  majority  of  cases,  will  be  safe  from  any 
tetanic  complication. 


SUMIMARY  OF  THE  FORMS  OF  TETANUS 

CLASSICAL  FOmi 

Incidence. — Since  the  introduction  of  preventive 
serotherapy,  less  frequent  than  formerly.  Statistics 
relating  to  present  war  show  that  frequency  may  var^' 
from  11-8  per  1000  (Bazy)  to  -1  per  1000  (Vallette). 

Symptojnatology. — A  usually  brief  prodromal  period 
is  observed  in  four-fifths  of  the  cases,  and  is  character- 
ised by  neuralgic  pains  in  the  vicinity  of  the  wound, 
and  dull  or  shooting  or  sometimes  fulgurant  pains  along 
the  course  of  the  nerves  in  its  neighbourhood,  with 
spasms,  stiffness,  and  slight  and  transitor}^  contractures 
of  the  various  muscles  of  the  wounded  area.  The 
subject  is  next  attacked  by  trismus.  Then  the  neck 
muscles  become  stiff ;  dysphagia  appears  ;  the  facial 
muscles  are  affected,  causing  risus  sardonicus.  The 
body  is  arched — opisthotonos. 

The  muscles  of  the  abdomen  become  contractured, 
then  those  of  the  limb.  The  entire  body  now  becomes 
completely  rigid. 

The  contractures  are  usually  intermittent,  but  recur 
on  the  slightest  movement  or  stimulation.  Occasion- 
ally contracture  is  localised  to  trismus  without  general- 
isation. 

High  fever— 104°  F.  up  to  even  107-5°  F. 

Often  there  is  retention  of  urine. 

Lastly,  the  respiratory  muscles  are  affected  and  the 
patient  succumbs  to  asphyxia. 

913 


914       THE  ABNORMAL  FORMS  OF  TETANUS 

Sometimes  emprosthotonos,  pleurothotonos,  or  ortho- 
tonos  replace  the  opisthotonos. 

Diagnosis. — Easy  when  symptoms  are  complete. 
(1)  If  trismus  is  the  only  sign  at  outset  eliminate. 
Mental  affections  and  angina. 

(2)  Acute  strychnine  poisoning  gives  rise  to  similar 
symptoms. 

Prognosis. — Grave.  Mortality  despite  serotherapy 
is  still  high.  Recent  statistics  show  a  death-rate 
amounting  to  64  per  cent. 


ABNORMAL  FORMS 

A.  Sphlancnic  Tetanus 

Incidence. — Very  rare.  It  occurs  in  man  quite 
exceptionally  after  abdominal  operations  or  uterine 
wounds. 

Symptomatology. — Long  incubation.  Short  duration 
of  the  malady. 

Non-generalisation  of  the  contractures  which  involve 
the  muscles  of  deglutition  and  respiration. 

Dyspnoea  is  marked  and  always  alarming. 

Diagnosis. — Eliminate  hydrophobia. 

Prognosis. — Always  fatal. 

B.  Cephalic  Tetanus 

(1)  Non-paralytic  Type 

Incidence. — Very  rare.  No  signs  of  facial  paralysis. 
Always  wound  of  head. 

Symptomatology.  (a)  Simple  cephalic  tetanus. 
Trismus  only  with  contraction  of  certain  face  muscles. 

{b)  Dysphagic  form.     Pharyngeal  spasms  rendering 


SUMMARY  OF  THE  FORMS  OF  TETANUS      9L5 

alimentation  difficult.  Sometimes  respiratory  muscles 
affected. 

(c)  Hydrophobic  tbrm.  Violent  convulsive  spasms, 
starting  in  wound,  radiating  to  muscles  of  neck,  face, 
and  pharynx,  finally  reaching  the  diaphragm,  to  cause 
grave  respiratory  disturbance. 

Diagnosis. — Eliminate  true  hydrophobia  in  types 
(6)  and  (c). 

Prognosis. — Type  (a)  grave.  Still  more  gloomy  if 
respiratory  disorders  appear. 

In  the  dysphagic  and  hydrophobic  forms  nearly 
always  fatal. 

(2)  Paralytic  Type 

Incidence. — Rare.  Follows  a  wound  of  head  in  the 
region  innervated  by  the  trigeminal. 

Symptomatology. — Facial  paralysis  with  contractures 
localised  principally  in  the  cephalic  region,  above  all  in 
the  facial  region,  but  the  tetanus  may  slowly  invade 
other  regions. 

Facial  paralysis  may  precede,  follow,  or  accompany 
the  contractures.  It  is  usually  unilateral,  occurring 
on  the  same  side  as  the  wound.  If  the  wound  is 
median,  there  may  be  facial  diplegia.  The  paralysis 
may  be  partial  or  complete. 

Complete  facial  paralysis  affects  the  whole  seventh 
nerve,  and  may  cause  hyperacusis  and  disorders  of  taste. 

Partial  facial  paralysis  may  involve  either  the  upper 
or  lower  branches  of  the  facial  nerve. 

Diagnosis. — Eliminate  (1)  direct  traumatism  involv- 
ing the  facial  nerve ;  (2)  hysteria  ;  (3)  tic  douloureux  ; 
(4)  traumatic  reflex  spasms. 

Prognosis. — Less   gloomy   than   in   usual    forms   of 


916       THE  A  By  OEM  A  L  FORMS  OF  TETAyUS 

tetanus.  Mortality  in  France  does  not  exceed  50  per 
cent.  The  facial  paralysis  usually  disappears  without 
leaving  permanent  traces  when  the  patient  recovers 
from  the  tetanus. 

(3)  With  Paralysis  of  the  Motor  Nerves  of  the  Eye 

Incidence.  —  Comparatively  rare.  Occurs  when 
tetanus  follows  trauma  of  the  eye  and  adjacent  parts. 

Symptomatohgy. — ^Occasionally  ocular  paralysis  is 
earliest  manifestation. 

The  third  nerve  is  always  involved ;  the  fourth  and 
sixth  may  be  paralysed  also. 

ptosis,  strabismus,  and  a  more  or  less  complete 
paralysis  of  the  external  muscles  of  the  eye  are  the 
ordinar\^  s\Tiiptoms. 

The  internal  muscles  of  the  eye  may  be  affected  also. 

This  form  may  coexist  with  facial  paralysis. 

Diagnosis. — Eliminate  (1)  ocular  spasms ;  (2)  cerebro- 
spinal meningitis  ;  (3)  tubercular  meningitis ;  (4)  fracture 
of  the  orbit ;   (5)  fracture  of  the  base  of  the  skull. 

Prognosis. — Cases  of  ophthalmoplegic  tetanus  have 
been  fatal.  Chronicity  is  in  favour  of  recover}\ 
The  prognosis  of  the  ocular  paralysis  yer  se  is  good. 
In  only  one  case  did  the  ophthalmoplegia  last  three 
months. 

(4)  With  Paralysis  of  the  Hypoglossal  (Rare) 

Symptomatology.  —  S\Tidrome  of  labio-glosso-laryn- 
geal  paralysis. 

C.  Un'ilateeal  Tetanus 

Incidence. — Existence  debated.  In  any  case,  exceed- 
ingly rare. 


SUMMARY  OF  THE  FORMS  OF  TETANUS      917 

Symptomatology. — In  general  the  symptoms  are  for 
some  time  confined  to  one  side  of  the  body,  and  are  still 
predominant  there  dming  generalisation,  giving  rise  to 
pleurothotonos. 

Diagnosis. — Eliminate  irritative  cortical  lesion. 

Prognosis. — ^That  of  classical  form  of  tetanus. 

D.  Tetanus  of  the  Limbs 
(1)  Monoplegic  Form 

Incidence. — Rare.  But  observations  more  frequent 
since  first  case  published  by  Courtellement. 

Symptomatology. — The  first  s^Tnptoms  consist  of  a 
slight  stiffness  either  of  the  muscles  of  the  wounded 
limb  or  the  masseters.  The  onset  may  be  early  or  late. 
The  first  signs  are  usually  pain  in  the  wounded  limb, 
soon  followed  by  a  localised  contracture.  Clonic  move- 
ments occurring  in  paroxysms  may  first  appear, 
followed  by  tonic  contracture,  or  the  contracture  may 
be  the  first  symptom,  the  limb  feeling,  on  palpation, 
like  a  mass  of  wood. 

Sometimes  there  is  slight  transitory  trismus.  There 
is  little  or  no  stiffness  of  the  neck. 

There  is  often  a  more  or  less  marked  contracture  of 
the  abdominal  muscles. 

There  is  little  fever.  Temperature  is  about  100-5° 
to  101-5°  F. 

The  pulse  is  moderately  rapid — 100  to  120  per 
minute.     Not  irregular. 

The  facial  expression  is  anxious. 

There  is  constant  exaggeration  of  the  deep  reflexes, 
often  with  ankle  and  patellar  clonus  and  h\-per- 
excitability  of  muscles  and  nerves  under  electrical 
stimulation. 


918       THE  ABNORMAL   FORMS  OF  TETANUS 

Diagnosis. — Eliminate  (1)  spasmodic  monoplegia  due 
to  cerebral  or  medullary  lesion  ;  (2)  irritation  of  motor 
and  mixed  nerves  ;  (8)  contractures  due  to  lesions  of 
bones  and  joints ;  (4)  tetany  ;  (5)  hysterical  contracture. 

Prognosis. — If  development  be  chronic,  there  is  a 
tendency  toward  recovery.  The  prognosis  is,  however, 
grave,  on  account  of  possible  complications  or  secondary 
generalisation. 

Routier  observed  six  cases  with  three  deaths.  Never- 
theless, it  often  tends  toward  recovery,  except  in  cases 
of  late  post-operative  tetanus. 

(2)  Paraplegic  Form 

Incidence. — Rare. 

Symptornatology. — According  to  the  seat  of  the  con- 
tractures one  may  distinguish : 

(a)  Superior  paraplegic  form.  Upper  arm,  forearm 
and  hands  forcibly  flexed. 

(b)  Inferior  paraplegic  form.  Limbs  in  forced  exten- 
sion. Foot  in  position  of  talipes  equinus.  Lower  leg 
extended  from  the  thigh,  the  patella  strongly  inmiobil- 
ised.  The  thigh  extended  at  the  pelvis.  The  whole 
limb  hard,  as  if  petrified. 

Diagnosis. — Eliminate  tetany,  hysterical  paraplegia, 
lesion  of  cord. 
Prognosis. — Favourable.    Recovery  the  rule. 

E.  Localised  Tetanus — ^Abdominal  Thoracic  Type 

(One  Case) 

Symptomatology. — Tetanus  confined  to  the  abdomino- 
thoracic muscles.  Not  affecting  other  groups  of 
muscles  except  masseters,  which  are  slightly  affected. 


SUMMARV  OF  THE  FORMS  OF  TETANUS      919 

F.  Attenuated  Tetanus  developing  slowly 
AFTER  A  PROLONGED  Incubation  (Very  Rare) 

Symptomatology. — ^The  first  symptoms  consist  of  a 
slight  stiffness,  either  of  the  muscles  of  the  wounded 
limb  or  the  masseters.  The  facial  expression  is 
abnormal. 

The  general  condition  remains  excellent,  and  the 
patient  is  able  to  walk.  Muscular  hypertonia  without 
paroxysmal  contractions. 

Temperature  normal. 

Exaggeration  of  the  deep  reflexes  and  excessive 
excitability  of  the  muscles  and  nerves  to  electrical 
stimulation. 

Diagnosis. — Eliminate  hysterical  conditions. 

Prognosis. — Good. 


TETANUS 

Tetanus   represents  a  widely  distributed  wound  in- 
fection, especially  in  the  Western  theatre  of  war,  on  ac- 
count of  the  contamination  of  the  French  and  Flemish 
soil  with  tetanus  bacilli  and  the  strenuous  fighting  in 
wet  inclement  weather.     A  recent  analysis  oflPered  by 
Sir  Wm.  B.  Leishman  and  A.  B.   Smallman   (Lancet, 
I,  1917,  p.   131)    is  based  upon   160  cases  which  oc- 
curred  in   hospitals   in  France  between  July   1st  and 
October  31st,  1916.     Of  these  cases  118  died  and  42 
recovered,   a  case  mortality   of  73.7   per  cent.      In   a 
preceding  group   of  cases  examined  in  the   spring  of 
1915   the   case-mortality  amounted  to   78.2   per   cent. 
The  high  death  rate  in  France  is  due  to  the  ease  with 
which   the    infection    occurs    in   patients    too    seriously 
wounded  for  transportation  to  home  hospitals  in  Eng- 
land, and  to  the   relative  frequency  of  gas  gangrene 
and  sepsis  superadded  to  the  tetanus.     Of  351   cases 
reported  by  German  observers,  242  died  and  109  re- 
covered, equalling  a  mortality  of  70  per  cent;  in  the 
beginning,  nearly  all  the  patients  died,  the  mortality 
later  on  dropping  to  about  65  per  cent.     The  onset  of 
the   disease   was   essentially  lessened   through  prophy- 
lactic inoculations   with   tetanus   antitoxin,   even   after 
very  grave  shell  and  shrapnel  injuries,  otherwise  a  fruit- 
ful source  of  tetanus  infection.     Prophylactic  injection 
of  protective  serum  Is  a  routine  measure  at  the  front. 

9^0 


EDITORIAL  NOTE  021 

Tetanus  lias  been  repeatedly  knoTvn  to  follow  on  pro- 
longed exposure  of  wounded  soldiers  to  cold  and  wet. 
In  the  current  war,  soldiers  with  frost-bitten  feet  have 
often  become  the  victims  of  hyperacute,  so-called 
splanchnic  tetanus.  As  pointed  out  by  Vincent  (La 
Presse  Medicale,  1  Nov.,  1917,  p.  632),  the  soaking  of 
the  men's  feet  for  hours  in  the  chilly  water  of  the 
trenches  ultimateh^  leads  to  oedema  and  trophic  dis- 
turbances. The  spores  of  the  tetanus  bacillus  find  an 
entrance  avenue  in  the  existing  small  erosions  of  the 
foot.  The  activity  of  the  leucocytes  is  inhibited  b}'  cold 
below  15°,  which  renders  them  unable  to  take  up  the 
spores.  The  surviving  tetanus  bacilli  flourish  in  the 
oedematous  fluid  when  the  limb  becomes  warm,  and  the 
final  absorption  of  this  poisonous  oedema  is  equivalent 
to  an  injection  of  tetanus  toxin.  Acute  symptoms  may 
therefore  supervene  an  spite  of  the  serviceable  protective 
injections  of  antitetanic  serum.  The  skin  and  the  sub- 
jacent tissues  remain  infiltrated  and  oedematous  for 
several  da3^s.  The  retarded  circulation  possibl}'  ac- 
counts for  the  difficult  access  of  the  antitetanic  serum 
to  the  imperfectly  irrigated  territory.  The  oedema 
and,  therefore,  also  the  onset  of  tetanus  infection  are 
favored  by  constricting  foot-  and  leg-gear,  which 
shrinks  under  the  influence  of  moisture.  The  wearing 
of  large  well-greased  shoes  and  woolen  socks  impreg- 
nated with  formol  ointment  is  therefore  recommended 
as  a  precautionary  measure. 

The  quotation  of  the  following  sunmiary,  given  by 
Dr.  Leon  H.  Cornwall  at  the  end  of  his  paper  on  war 
tetanus — published  by  permission  of  the  Surgeon  Gen- 
eral; New  York  Med.  J.,  Oct.  2T,  1917,  p.  773— con- 
veys in  condensed  fonn  the  present  status  of  knowledge 


922  TETANUS 

in  regard  to  the  incidence,  management,  and  prevention 
of  this  wound  infection : 

1.  Tetanus  is  a  common  scourge  of  war. 

2.  In  the  present  war  there  have  been  more  cases  of 
tetanus  per  1,000  than  in  any  previous  war. 

3.  Tetanus  develops  after  Avounds  contaminated  by 
dirt  and  clothing,  and  is  more  frequent  after  wounds  of 
the  extremities  than  those  of  other  regions. 

4.  The  usual  incubation  period  is  from  six  to  sixteen 
days,  but  in  tardy  tetanus  may  be  prolonged  to  three 
months. 

5.  Low  temperature  and  free  access  of  oxygen  pro- 
long the  period  of  incubation. 

6.  The  onset  is  frequently  so  insidious  as  to  render 
early  diagnosis  difficult. 

7.  The  pathway  of  the  infection  is  along  the  peri- 
neural lymph  channels  to  the  spinal  cord. 

8.  Early  prophylactic  injection  of  antitoxin  should 
be  given  in  every  wound  contaminated  by  dirt  or  par- 
ticles of  clothing. 

9.  For  therapeutic  purposes  the  serum  should  be 
given  subcutaneously,  intravenously,  intraspinally,  and 
endoneurally. 

10.  To  prevent  the  muscular  fatigue  due  to  spasms 
and  convulsions,  sedatives  are  of  great  value,  and  abso- 
lute rest  is  of  paramount  importance. 

11.  So-called  tardy  tetanus  may  occur  as  late  as 
three  months  after  injury,  and  is  especially  likely  to  fol- 
low secondary  surgical  operations  or  other  trauma  at 
or  near  wounds  previously  infected  with  tetanus  bacilli. 

12.  The  prognosis  is  grave  when  the  disease  develops 
early,  but  late  cases  have  a  favorable  prognosis. 

Treatment. — The  treatment,  as  mentioned  by  Corn- 
wall,   consists    of    three    varieties :    General,    local,    and 


EDITORIAL  NOTE  023 

regiminal.  The  general  treatment  consists  of  the  use  of 
antitoxin  and  drugs.  liOcally,  the  treatment  includes 
the  use  of  antitoxin  for  its  neutralizing  effect,  antisep- 
tic surgical  care,  and  the  injection  of  medication  with 
bacterial  action,  such  as  phenol  and  peroxide.  Absolute 
quiet  comprises  the  major  part  of  the  regimen. 

"For  the  administration  of  antitoxin  four  methods  are 
employed:  subcutaneous,  intravenous,  intraspinal,  and 
endoneural.  In  every  wound  contaminated  by  dirt  or 
pieces  of  clothing,  and  especially  wounds  of  the  extremi- 
ties, a  prophylactic  injection  of  1,000  to  2,000  units 
should  be  given  subcutaneously  at  or  near  the  site  of 
injury.  Tlie  value  of  the  local  injection  of  antitoxin 
in  prophylaxis  is  due  to  the  fact  that  it  prevents  the 
absorption  of  the  tetanus  toxin  from  the  wound  by 
combining  with  and  neutralizing  it.  If,  however,  the 
toxin  has  been  absorbed  by  the  nervous  system,  this 
method  is  of  no  avail.  One  initial  prophylactic  dose 
is  not  sufficient  but  should  be  repeated  weekly  for  three 
doses  or  until  the  wound  is  healed.  After  the  develop- 
ment of  symptoms  the  subcutaneous  method  alone  is  in- 
sufficient. It  is  imperative  at  this  stage  to  combine  with 
it  one  or  more  of  the  other  metliods :  intravenous,  intra- 
spinal, or  endoneural.  For  therapeutic  purposes  an  in- 
traspinal injection  of  3,000  to  5,000  units  should  be 
combined  with  10,000  units  intravenously  at  the  same 
time.  The  intraspinal  dose  should  be  repeated  daily 
until  the  symptoms  subside,  and  NicoU  (Jour.  Am.  Med. 
Assoc,  1915,  LXV,  No.  24.,  p.  1983)  advises  10,000 
units  subcutaneously  on  the  third  or  fourth  day." 

The  alternative  channels  of  administration  of  the  anti- 
toxin are  placed  by  Leishman  and  Stillman  (loc.  cit.) 
in  the  following  order  of  merit:  Intramuscular,  sub- 
cutaneous, intrathecal,  and  intravenous.     They  have  a 


924  TETANUS 

decided  impression  that  the  intratliecal  route  may  be  a 
dangerous  one:  and  think,  on  grounds  both  of  theory 
and  observation,  that  the  subcutaneous  and  intramus- 
cular routes  might  be  promoted  to  a  more  dignified 
position  than  as  merely  supplementary  to  the  other 
routes.  In  their  .experience  with  a  series  of  cases,  the 
results  of  these  two  methods  of  introducing  antitoxin 
were  beti;er  than  those  of  either  the  intrathecal  or  the 
intravenous  methods.  Should  the  wound  be  a  single 
one,  and  especially  if  it  is  on  a  limb,  they  believe  it 
would  be  sound  practice  to  introduce  antitoxin,  both 
subcutaneously  and  intramuscularly,  somewhere  astride 
the  path  which  the  toxin  must  travel  on  its  way  to  the 
spinal  cord.  "To  do  this  effectually  it  would  appear, 
if  our  ideas  are  correct,  better  to  divide  the  ck>se  and 
inject  portions  on  each  surface  of  the  limb  and  also  at 
different  depths  amid  the  muscles.  Somewhere  among 
these  tissues  we  know  the  nerves  run  along  which  the 
poison  is  traveling,  and  the  more  evenly  distributed  our 
antitoxin  the  better  would  appear  the  chance  that  it 
may  attain  effective  contact  with  the  toxin  and  achieve 
our  object." 

The  value  of  intramuscular  administration  of  tetanus 
antitoxin  has  been  widely  questioned  and  a  number  of 
writers  have  protested  against  this  recommendation. 
The  British  War  Office  Committee  for  the  study  of 
tetanus  in  its  Memorandum,  published  in  November, 
1916.  distinctly  states  that  m  a  case  of  tetanus  the 
first  thing  to  do  is  to  give  an  intrathecal  injection  of 
antitoxin,  as  this  route  is  the  most  valuable. 

Amputation  of  badly  shattered  extremities  is  some- 
times the  wisest  procedure,  in  order  to  restrict  the  con- 
tinued absorption  of  toxins  a«d  thereby  improve  the 
patient's  prospects  of  recovery. 


EDITORIAL  NOTE  925 

General  Treatment  of  Tetanus  Patients. — In  order  to 
guard  against  reflex  irritation,  these  patients  should 
be  kept  in  a  dark  and  quiet  room,  as  free  as  possible 
from  disturbances  of  all  kinds.  They  should  be  care- 
fully nourished  with  liquid  foods,  as  they  are  usually 
unable  to  swallow  or  chew  solid  morsels.  Rectal  feed- 
ing or  gavage  are  sometimes  necessary.  The  more  rest 
and  sleep  the  patient  can  secure  the  better  his  prospects 
of  recovery.  Sedative  drugs,  such  as  bromides  and 
chloral,  are  often  of  use  for  the  relaxation  of  the  spasm 
and  the  relief  of  the  general  restlessness. 

Ultra  Violet  Light. — The  spores  of  the  tetanus  bacil- 
lus are  extremely  susceptible  to  the  action  of  ultra 
violet  light,  and  in  civil  practice  the  radiation  of  in- 
fected wounds  with  the  quart  lamp  has  been  known  to 
result  in  the  total  destruction  of  the  tetanus  bacilli. 
Radiotherapy  is  a  useful  supplement  to  other  curative 
procedures,  but  the  careful  surgical  cleansing  of  the 
wound  must  never  be  neglected,  on  account  of  the  abun- 
dant toxin  contents  of  the  infectious  focus. 

Curare  has  recently  been  recommended  in  the  treat- 
ment of  tetanus,  as  counteracting  one  of  the  most  Han- 
gerous  complications,  namely,  spasm  of  the  respirator}^ 
muscles. 

Magnesium  Sulphate. —  In  the  treatment  of  tetanus, 
magnf'sium  sulphate  has  been  successfully  employed, 
both  subcutaneously  and  in  intraspinal  injections.  It 
acts  as  an  anaesthetic  and  induces  muscular  relaxation. 
The  dose  is  15  to  20  c.c.  of  a  20  per  cent  solution,  or 
12  to  16  c.c.  of  a  25  per  cent  solution,  three  times 
daily.  Phenol  and  hydrogen  peroxide  have  occasionally 
proved  successful  in  subcutaneous  and  local  applica- 
tion to  the  wound.  Oxidizing  agents  such  as  potassium 
perjuanganate,  chlorin  water  and  iodin  solution  exert 


926  TETANUS 

an   inhibitory   action    on   the   an.Trobic   growth   of   the 
tetanus  bacillus. 

Sodium  Persulphate. — Dr.  Leyva,  on  the  basis  of 
some  personal  observations  in  the  American  Ambulance 
Hospital  in  Paris  (Surg.  Gyn.  Obs.,  Dec,  1917,  p. 
613),  finds  that  sodium  persulphate  combined  with  the 
antitetanic  serum  relieves  the  pains  and  spasmodic  at- 
tacks to  such  an  extent  that  the  patient  begs  to  be  given 
the  injections.  The  minimum  dose  must  be  60  c.c.  in 
one  day.  The  solution  must  be  freshly  prepared  and 
kept  in  a  shaded  place,  as  both  heat  and  light  decom- 
pose it.  In  the  American  Ambulance  Hospital  the 
solution  was  prepared  in  doubly  distilled  water,  usiiig 
the  persulphate  of  sodium  in  scaled  bottles  prepared  by 
the  firm  Lumiere  of  Paris. 

In  the  management  of  wound  infection  by  the  tetanus 
bacillus,  antitetanic  serum  has  been  found  to  be  a  de- 
fensive measure  of  the  first  rank,  not  only  protective, 
but  curative,  and  absolutely  indicated  in  all  cases.  In 
the  presence  of  established  tetanus,  even  when  the  pre- 
ventive injection  has  been  neglected,  excellent  results 
may  be  anticipated  from  its  use  in  sufficient  dosage  and 
suitable  administration,  preferably  by  the  intraspinal 
route.  Tetanus  developing  in  spite  of  a  preventive  in- 
jection is  very  amenable  to  serum  treatment,  and  the 
patients  are  almost  without  exception  saved  by  intra- 
spinal administratio»i  of  graded  doses  of  antitoxin. 

[Editorial  Note.] 


BIBLIOGRAPHICAL  INDEX 

(To  1916) 

(Titles  of  German  Essays  translated  into  English, 
AND  IN  Brackets) 

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Armee,  19avril  1916. 
Albert. — Etudes  sur  le  tetanos  cephalique.     TMsedeLyon,  1890. 
Arnd  and  Kumbein. — (Treatment  of  tetanus  by  Bacelli's  method.) 

Corr.  Blatt.  jiir  Schweizer  Aerzte,  1914,  No.  48. 
AsHURT  and  John. — The  rational  treatment  of  tetanus.     The  Amer. 

Journal  of  Medical  Science,  June  and  July  1913. 
AuBOYER. — Tetanos  chronique  a  rechute,  cause  par  la  persistance  du 

projectile  dans  la  blessure.     Paris  medical,  1915,  p.  402. 
Bacri. — Traitement  precoce  du  tetanos  dans  les  hopitaux  militaires 

en  temps  de  guerre.     Acad,  de  Medecine,  23  mars  1915,  p.  383. 
Barnsby  et  Mercier. — Guerison  de  6  cas  de  tetanos  traumatique 

par  la  methode  intra-veineuse.     Acad,  de  Medecine,  23  mars 

1915. 
Bazy. — A  propos  du  tetanos.     Acad,  dea  Sciences,  14  decembre  1914. 

— Valeur  preventive  du  sertmi  antitetanique.     Presse  medicale, 

4  fevrier  1915. — Tetanos  tardif.     Acad,  des  Sciences,  24  Janvier 

1916,  Acad,  de  Medecine,  16  mai  1916. 
Belot. — (A  case  of  cephalic  tetanus  with  paralysis  of  the  hypo- 
glossal.)     Wiener  Klin.  TFoc^ensc/i.,  23rd  April  1903,  p.  500. 
Berard  et  LuMiijRE. — Acad,  de  Medecine,  31  aout   1915. — Sur  le 

tetanos  tardif,  revolution  clinique  du  tetanos  tardif,  survenant 

apres  I'injection  preventive  de  s6rum.     Lyon  chir.,  octobre  1915, 

p.  409  ;  Acad,  de  Medecine,  16  mai  1916. 
Bienfait   et  Leroy. — Contribution    a   I'etude    du    traitement    du 

tetanos  par  les  injections  intra-rachidiennes  de  sulfate  de  mag- 

nesie.     LeCaducee,  15juillet  1915,  p.  85. 
BiNET  et  Trenel. — Le  tetanos  cephalique.     Revue  de  Chirurgie,  /, 

1909. 
BiNOT. — i^tude  experimentale  sur  le  tetanos.     Annales  de  V Institut 

Pasteur,  1900. 

Q  927 


928  BIBLTOGRAFHICAL  INDEX 

Blttmenthal. — (Remarks  on  the  symptomatology  and  treatment  of 

tetanvis.)     Medezin  Klin.,  1914,  No.  44. 
BoiNET  et  MoNQES.— Tetanos  traumatique  gueri  a  la  suite  de  Tinjec- 

tion  sous-arachnoYdienne,  sous-cutanee  ©t  intra-musculaire  de  790 

centimetres  cubes  de  serum  antitetanique.     Province  Medicale, 

1910,  p.  386. 

BoQUEL. — Traitement  de  24  cas  de  tetanos  chez  des  blesses  militaires. 

Bulletin  Acad,  de  Medecine,  8  et  14  decembre  1914. 
Bouquet. — Deux  cas  de  tetanos  localise  tardif.     Bulletin  de  ThSra- 

peutique,  fevrier  1916. 
Bboca. — Journal  des  Prat.,  10  avril  1915. 
Brocket. — (Note  de  M.  Bertrand.)     Tetanos  localise  tardif  simulant 

une   occlusion   intestinale.     Seance   et   Bulletin   de   V Acad,   de 

Midecine,  23  novembre  1915,  No.  47. 
Brum,  — jRaccourcissement  musculairQ  posterieur  au  tetanos.  Bulletin 

Acad,  de  MSdecine,  18  decembre  1896. 
Bbun. — The  treatment  of  tetanus  by  the  rational  method  of  Ashurt 

and   John.     Development   of    a    purulent   aseptic   meningitis 

consecutive  upon  the  intraspinal  injection  of  tetanic  antitoxin. 

The  Journal  of  the  Amer.  Med.  Assoc,  17th  January  1914. 
Brunet. — Considerations    sur    quelques    cas    de    pseudo-t^tanos. 

These  Bordeaux,  1901-1902,  No.  33. 
Caillaud    et    CoRNiGLiON. — Traitement    du    tetanos.      Acad,    de 

Medecine,  10  novenxbre  1914  ;    Acad,  des  Sciences,  3  novembre 

1914. 
Capitan. — Acad,  de  MSdecine,  30  novembre  1914. 
Carnot. — Tetanos   local   et    tardif  apres   serotherapie   preventive. 

Paris  medical,  1916,  p.  541. 
Castuel  et  Ferrieb. — Sur    16   cas  de  t6tanos  observes  a  Vitr6. 

Acad,  de  Medecine,  20  juillet  1915. 
Cazamian. — Sur  un  cas  de  tetanos  grave  gu6ri  par  le  s6rum  ;   injec- 
tions mixtes  intra-rachidiennes  et  intra-veineuses.     Arch.  Mid 

et  Ph.  navales,  aout  1914. 
Cazin. — De  I'utilite  des  injections  repetees  de  serum  dntitetanique 

dans  le  traitement  preventif  du  tetanos.    Soc.  Chir.,  12  novembre 

1915. 
Chamayou.^ — Un  cas  de  tetanos  gueri.     Arch.  Mid.  de  Toulouse^  !«' 

mai  1913. 
Chaput. — Le  traitement  .preventif  du  tetanos  par  la  disinfection  pri- 

coce  et  radicale  et  le  traitement  antiseptique.     Preeae  nUdiccUe, 

3  decembre  1914. 


i 


BIBLIOGRAPHICAL  INDEX  929 

Chatenei?  de  Giby. — Le  traitement  du  tetanos  coofirme  par  lA 

m6thode  de  Bacelli.     Gazette  des  Hdpitaux,  d6cembre  1915. 
Chauffabd. — Les  sjmdromes  tetaniques.     Journal  dea  PraticienSt 

9mai  1914. 
Chobaith. — Notes  sur  le  tetanos  de  la  guerre  de  1914.     TMee  de 

Paris,  mars  1915. 
Claude  et  Lheemitte. — Le   tetanos  fruste  a  Evolution  lente  et 

incubation  prolongee.     6tude  des  reactions  ^lectriques.     Preaae 

rrUdicale,  14  octobre  1915,  p.  406. 
CoMBY. — Trois  cas  de  tetanos  gueris  par  injections  sous-cutanees  de 

serum  antit^tanique.     Soc.  Mid.  des  Hdpitaux,  9  octobre  1914. 

— Traitement  du  tetanos  par  les  injections  sous-cutan6es  de 

s^rum  antit^tanique.     Arch.  Mid.  inf.,  septembre  1915,  Nos. 

490  et  497. 
CoBNiGLiON. — Traitement  du  tetanos  par  les  injections  pheniquees 

aqueuses  au  centieme  avec  adjonction  de  serum  ipde.     Journal 

Midecine  et  Ghirurgie  prat.,  25  juin  1915,  p.  449. 
CouBMONT  et  Cobdieb. — Deux  cas  de  tetanos  chei  le  mime  sujet  k 

cinq  ans  de  distance.     Lyon  Midical,  4  decembre  1910. 
CouBMONT  et  DoYON. — Lc  tetanos.     /ictualitis  medicates,  1899. 

CouBTELLEMONT. — Tetanos  ut^rin  k  forme  chronique ;  injections 
6pidurales  de  servim  antitetanique  et  traitement  medicamenteux, 
gu^rison.  Progria  midical,  1911,  p.  404. — Les  tetanos  partiels 
et  en  particulier  les  tetanos  partiels  des  membres.  Paris 
midical,  1915,  p.  3. 

CouBTOis-SuFFiT  et  Ren^  Giboux. — Tetanos  parti  el  localise  au 
membre  inferie\ir  gauche.     Acad,  de  Medecine,  25  Janvier  1916. 

CouTEAUX. — Quelques  formes  anormales  du  tetanos.  Soc.  Chir., 
16f6vrier  1916. 

Cbespik. — Contribution  k  I'^tude  du  tetanos  chronique.  T?iea6  de 
Paris,  1907-1908,  No.  304. 

CuBTiLLBT  et  LoMBABD. — T6tanos  apparu  malgre  une  injection  pre- 
ventive de  s6rvun  antitetanique.     S6rotherapie. 

Dawson. — Chronic  cephalic  tetanus.  The  American  Med.  Journal, 
July  1910,  p.  548. 

Delabboxtsse. — T6tanos  k  orme  lente.  La  Normandie  medicate,  l^r 
f6vrier  1909. 

Delbet. — Discussion  sur  le  r^veil  de  I'infection  des  plaies.  Soc, 
Chir,,  octobre  et  novembre  1915. 

Deleuze. — Quelques  apergus  des  publications  m^dioales  aUemandes. 
Presse  midicale,  13  d^oembre  1916. 


930  BIBLIOGRAPIIJCAL  INDEX 

Delobme. — Precis  de  Ghirurgie  de  guerre.  Masson  et  Cie,  editeurs, 
1914,  p.  100  ;  Presse  medicale,  8  octobre  1914. 

Demmxeb. — Sur  le  traitement  du  tetanos  par  les  doses  elevees  de 
chloral.     Acad,  de  Medecine,  3  novembre  1914. 

Demontmebot. — De  la  forme  paraplegique  dans  le  tetanos  chronique. 
These  de  Paris,  jtiillet  1904. 

Desplas. — Tetanos  local  tardif  mortel.  Reunion  Mid.  F/*  Armee, 
decembre  1915. 

D'Hotel  (de  Poix). — Injections  intra-rachidiennes  de  serum  anti- 
tetanique  faites  le  malade  etant  place  en  declivite  bulbaire. 
Acad,  de  Medecine,  27  octobre  1914,  p.  229. 

Doyen. — Traitement  du  tetanos  par  les  injections  intra-rachidiennes 
de  serum  antitetanique  a  hautes  doses  suivies  du  renversement 
du  tronc  en  position  de  declivite  bulbaire.  Soc.  Biol.,  31 
octobre  1914. 

Duponchel. — Discussion  Raymond  et  Schmidt. 

Dupb6-Schceffeb  et  Lb  Fue  — Syndrome  tetanoide  persistant, 
secondaire  a  une  plaie  du  sciatique  droit,  complique  d'un 
tetanos  aigu  grave  (tetanos  chronique).  Soc.  N eurologique, 
3juin  1915,  p.  689. 

DuTERTBE  (ISmile). — Le  tetanos  et  son  traitement  en  Allemagne, 
1914-1915.     (Consult  Bibliographic  allemande  in  this  work.) 

Esau. — (A  case  of  local  tetanus  of  the  hand.)  Deutsche  Medizin 
Wochensch.,  14th  April  1910,  No.  15. 

foiENNE  (G.). — Lajections  de  quinine  et  tetanos.  C.  R.  Societe  de 
medecine  de  Nancy,  10  mars  1915,  fasc.  5,  p.  145. — Quelques  faits 
povir  r etude  du  tetanos  et  de  son  traitement.  C.  R.  Societe  de 
medecine  de  Nancy,  26  mai  1915,  fasc.  6,  p.  457. — Serotherapie 
dans  le  tetanos  declare  et  traitements  combinees.  Paris  mkdical, 
No.  18,  avril  1916. 

Faligant. — Contribution  a  l'6tude  du  traitement  du  tetanos.  These 
de  Paris,  1915. 

Ferrier. — [jfetudes  des  variations  de  I'uree  dans  le  liquide  cephalo- 
rachidien,  le  sang  et  1' urine  des  malades  atteints  de  certaines  in- 
fections 6pid6miques.     J ournnlde Pharm.  etChimie,  1915,  p.  314. 

Fbicker. — Les  tetanos  partiels.     These  de  Lyon,  1916. 
Genouville. — Serotherapie  chez  un  blesse  ayant  eu  le  tetanos  quinze 
mois  auparavant.     Riunion  M6d  Chir.  Ve  .4rmee,  8  Janvier  1916. 
GoMMA. — Discussion  Raymond  et  Schmidt. 

Grober. — Formes  chroniques  prolongees  et  trainantes  du  tetanos.  ; 
M6d.  moderne,  1903,  p.  309. 


BIBLIOGEAPJIICAL  INDEX  931 

GuiLLAiN. — Sur  un  cas  de  tetanos  avec  guerison  chez  Tin  enfant  de 

5  ans      Reunion  Med.  Vie  Armee,  aout-septembre  1915. 
Halipb6  et  MoNTPEURT. — Tetanos  chronique  a  forme  paraplegique 

spasmodique.     Revue  Medicate  de  la  Normandie,  Rouen,  1908, 

p.  382-389  et  540-544. 
HartmAnn. — Chirurgie  de  guerre.     Paris  medical,  2  Janvier  1915. 
Hermart  et  Nguyen-Viet-An. — Sur  un  cas  de  tetanos  chronique. 

Bulletin  de  la  Societe  Medico-Chirurgicale  de  Vlndo-Ghine,  mai 

1913. 
HuscH. — Sur  un  cas  de  tetanos.     Revue  Medicale  de  VEat,  15  fevrier 

1914,  p.  112. 
JoLY. — JsTote  sur  21  cas  de  tetanos.     Acad,  de  Medecine,  26  Janvier 

1915. 
Klemm. — (Local    contractures  as  the  first  symptom   of    tetanus.) 

Deutsche   Zeitschr.   fiir  Chir.,   13th  Jan.    1896,   vol.   xiii.,  Nos. 

4  et  5,  p.  453. 
Labadie-Lagrave     et     Laubry. — Considerations     pathogeniques, 

cliniques  et  therapeutiques  sur  deux  cas  de  tetanos  chronique. 

Soc.  Medicale  des  Hopitaux,  29  avril  1894  ;    Tribune  medicale, 

1904,  p.  277-279. 
Laignel-Lavastine    et   Gougebot. — Nevrite    infectieuse,   typhoi- 

dique,  dysenterique,  tetanique.     Soc.  Neur.,  2  decembre  1915. 

Laurent  (Ch.). — Notes  sur  le  traitement  de  18  cas  de  tetanos  con- 

firm^s.     Lyon  chir.,  decembre  1915,  p.  786-788. 
Laval. — (Note  de  M.  Vaillard.)     Notes  sur  deux  cas  de  tetanos 

strictement  localises  au  membre  inferieur.     Bulletin  de  I'Acad. 

de  Medecine,  No.  47,  23  novembre  1915 ;  Rapport  de  M.  Pozzi, 

7  decembre  1915. 
Le  Fort. — Accidents  pseudo-tetaniques  chez  des  blesses  attemts  de 

lesions  des  nerfs  compliquees  de  la  presence  de  corps  etrangers. 

Acad,  de  Medecine,  17  aout  1916. 
Lb  Fur. — A  propos  des  injections  de  serum  anti tetanique.     SociStS 

dea  Ghirurgiens  de  Paris,  12  novembre  1915. 
L]§:aEB. — Injections  hjrpodermiques  d'oxygene  dans  le  traitement  du 

tetanos.     Soc.  Chir.,  3  mars  1915. 
Leriche. — Un  cas  de  tetanos  tardif  a  symptomatologie  fruste.     Lyon 

Chir.,  octobre  1915. — Deux  cas  mortels  de  tetaiios  tardif  post- 

op6ratoire  chez  des  bless6s  ayant  re5u  une  injection  de  serum 

longtemps  auparavant.     Soc.  Med.  des  Hop.,  19  novembre  1915. 

Leboux  et  ViOLLET. — Un  cas  de  meningite  cerebro-spinale  simtilant 
le  tetanos.     Presse  Medicale,  24  decembre  1908, 


932  BIBLIOGRAPHJCAL  INDEX 

L6vY  et  Plisson. — Considerations  sur  quelques  complications  in- 
fectieuses  des  blessures  de  guerre.     Lyon  Chir.,  novembre  1915. 

LiAUTEY. — Un  cas  de  t^tanos  chronique  chez  un  yieillard  de  72  ans. 
Bevue  midiccUe  de  Franche-ComtS,  1911. 

LpYONE   et  Abbami. — A  propos   des  t^tanos  retard^s.     Riunion 

Midicale  IV^  ArnUe,  llf6vrier  1916. 
LuGOHESi. — Traitement    du   tStanos  par  la  m^thode   de  Bacelli. 

Bulletin  Acad,  de  Midecine,  7  d6cembre  1914. 

LuMiiiBE. — Sur  I'emploi  du  persulfate  de  soude  dans  le  traitement 
du  t6tanos.     Lyon  Chir.,  octobre  1916,  p.  411. 

Manheimbk-Gombz. — Sur  le  traitement  du  t^tanos  d6clar6.  Soc. 
Mid.  de  Paris,  11  d^cembre  1914. 

Mabfan. — Innocuit^  des  injections  sous-cutan6es  de  s6rum  h6t6ro- 
gene.     Soc.  Med.  H&p.,  29  octobre  1916,  p.  899. 

Marie  (P.-L.). — Tetanos  tardif  localise  k  type  abdomino-thoracique. 

Paris  Medicale,  No.  28,  8  juillet  1916. 
Martin,    Salimbeni   et  Frasey. — Essai   sur    la    vaccination    defl 

chevaux  par  la  toxine  t^tanique  chauff^e.     Soci6U  Biologique, 

26  decembre  1914. 
Martin. — Rapport  k  la  Commission   pour   I'^tude  des  injections 

s6riques.     Soc.  Mid.  H6p.,  16  novelnbre  1915,  p.  1076-1092. 

DE  Massary. — Deux  cas  de  tetanos,  gu6ris  par  une  medication  com- 
binee  de  s6rum  aatit6tanique,  de  chloral,  de  morphine  et  de 
laudanum  et  d' injections  sous-cutan^es  d'acide  ph6nique  k 
hautes  doses.  Soc.  Mid.  H6p.,  6  novembre  1914. — Craintes 
d'anaphylaxie,  abstention  d' injection  serique,  tetanos  mortel. 
Soc.  Mid.  H&p.,  22  octobre  1916. 

Mauclairb. — SociSti  de  Chirurgie,  5  juin  1916. 

Maurice. — Necessity  des  injections  r6p6t6es  de  s6rum  antit6tanique 
pour  assurer  Tefficacite  du  traitement  pr6ventif  du  tetanos. 
Soc.  Mid.  Paris,  27  aout  1915. 

Mbqewatstd. — Le  tetanos  c^phaiique.     Bevue  Midicale  de  la  Suisse 

Bomande,  20  octobre  1913. 
Meroier. — A  propos  du  tetanos.     Acad,  de  Midedne,  23  mars  1915. 
M&aiEL. — Deux  cas  de  tetanos  partiel.     Soc.  Chir.,  2  f6vrier  1916. 

MfeRiEux. — Serum  antit^tanique  et  sous-gallate  de  bismuth.  Soc. 
Biol.,  mars  1916. 

Mn-iAN  et  Lesurb. — De  Taction  curative  du  s6rum  antit^tanique. 
Paris  Midicale,  16  octobre  1915,  p.  394. 


BIBLIOGRAPHICAL  INDEX  933 

MoNOD. — Tetanos  localise  au  membre  superieur  droit  sans  aucune 
participation  du  membre  gauche.  Bulletin  de  V  Acad,  de  Mede- 
cine.  No.  45,  9  novembre  1915,  et  No.  47,  23  novembre  1915. 

MoNTAis. — Sur  quelques  cas  de  tetanos  localise  a  la  region  blessee. 

Tetanos  medullaire.     Ann.  Inatitut  Pasteur,  aout  1915,  p.  368- 

378. 
DE  MoNTiLLE  et  Lesage. — Traitcment  du  tetanos.     Rlunion  midi- 

cale  Vie  Armie,  20  octobre  1915. 
MoRET. — Traitement    du   tetanos.     SociSte   de  pathol.  comparSe,   8 

juillet  1914. 
NiOAY. — Le  tetanos,  son  traitement,  son  pronostic.     Presae  MedicalCt 

21  Janvier  1915. 

NiviijRE. — 61  cas  de  tetanos  soignes  k  V  hdpital  civil  de  Vichy.  Acad, 
de  Medecine,  30  mars  1915. 

Orticoni. — Serotherapie   et  anaphylaxie.     Reunion  Mtd.  Chir.  X* 

Armee,  10  aout  1915. 
Pancot. — Un  cas  de  tetanos  chronique.     Gu6rison.     Nord  Medical, 

Lille,  1907. 

Parent. — Serum     antitetanique     et     accidents    seriques.     SocUtt 

Pathol,  comparee,  6  juillet  1915. 
Peraire. — Discussion  Maurice.     SociStS  Mkdicale  de  Paris,  27  aout 

1915. 
Perrin  (M.). — Anaphylaxie  s^rique  en  pouss^es  subintrantes.     lU 

Congr^  fran^ais  de  Midecine,  1910,  et  Revue  Medicate  de  TEst, 

1911,  No.  4,  p.  97. 
Petit  de  la  ViLLfeoN. — Six  mois  de  chinirgie  de  guerre  dans  un 

hopital  de  Tarriere.     SociSte  Chinirgicale,  11  aout  1915. 

Phelip  et  PoLiCARD. — Tetanos  probablement  influence  par  ime 
n^vrite  pr6alable  du  membre  blesse.     Soc.  Chir.,  5  mai  1915. 

Phocas  et  Rabaud. — Tetanos  tardif  ayant  entraine  la  deformation 
du  membre  fractur6.     Acad,  de  Medecine,  28  mars  1916. 

PiQNOL,  Brisset  et  Lemonnier. — A  propos  du  tetanos  et  de  la  sero- 
therapie intra-rachidienne  massive.  Societi  Chirurgicale,  6 
octobre  1915,  p.  1906. 

PoAN  DB  Sap  IN  COURT. — Du  tetanos  c^phalique  avec  paralysie  faciale. 
Th^se  de  Paris,  juin  1904,  No.  401. 

"Pozzi. — Une  observation  de  tetanos  localise  precoce.  Bulletin  de 
VAcad.  de  Midecine,  9  novembre  1915  et  8  decembre  1916. 

QuENxr. — Discussion  sur  le  reveil  de  1' infection  dea  plaies.  Sociiti 
de  Chirurgie,  octobre  1916. 


934  BTBLIOGRAPHICAL  INDEX 

QufsRY. — Reinjections  et  reactions  seriques.     Societe  Path,  compar&e, 

14  mars  1915. 
Ramirez    Martinez. — Contribution   a    I'^tude    du   t6tanos   tardif 

localise.     These  de  Montpellier,  27  jtiillet  1915. 

Rauzier  et  EsTOR. — Du  tetanos  tardif  localis6.     These  de  Albert 

Ramirez  Martinez,  27  jtiillet  1915. 
Raymond  et  Schmidt. — Tetanos  cryptog6netique  traite  et  gu^ri  par 

la  serotherapie.     Reunion  Medico-Chirurgicale  de  la  X«  Arm^e, 

secteur  Sud,  25  aout  1915. 
RocLTJ. — Serum  antitetanique  et  accidents  seriques.     Paris  Medical, 

1915,  p.  450. 
Roger. — Tetanos   local.     Reunion   Medico-Chirurgicale  de    la    Vie 

Armee,  19  avril  1916. 
RouiiiiAUD. — Discussion  Raymond  et  Schmidt. 

RouTiER. — Notes  a  propos  d'un  certain  nombre  de  cas  tetanos 
anormal.  Bulletins  de  VAcad.  de  Medecine,  No.  45,  9  novembre 
1915,  et  No.  48,  30  novembre  1915. 

Roy. — Observation  d'un  cas  de  tetanos  chronique  suivi  de  guerison. 

Recueil  de  memoir es  et  observations  sur  r  hygiene  et  la  medecine 

v6t^rinaire  militaire,  1898,  p.  447. 
RuFFEB  et  Crendiropoulo. — Sur  la  guerison  du  tetanos  chez  le 

cobaye.     Soc.  de  Biologic,  14  juin  1913. 
Sainton. — Traitement  du  tetanos  par  la  methode  de  Bacelli.  Bulletin 

Acad,  de  Medecine,  1  et  7  decembre  1914. 

Sainton  et  Maill^. — Note  sur  le  liqmde  c6phalo-rachidien  dans  le 

tetanos  et  son  absence  de  toxicite.     Bulletin  Acad,  de  Medecine, 

29  decembre  1914  et  4  Janvier  1915. 
Saissi. — Discussion   Cayen.     Societe  des   Ghirurgiens  de  Paris,    12 

novembre  1915. 
Schwartz  et  Moulonguet. — Sur  une  forme  anormale  de  tetanos 

compliquant    une    laparatomie    pour   perforation    intestinale. 

Paris  MSdical,  1915,  p.  101,  et  SocUtS  Chirurgicale,  octobre  et 

novembre  1915. 
SiEXJR. — Apparition  du  tetanos  chez  les  blesses  de  la  guerre.  Bulletins 

Acad,  de  Medecine,  12  et  18  Janvier  1915. 

Spili-mann  (L.). — Le  tetanos  a  I'hdpital  militaire  de  Nancy.  C.  R. 
SocUte  de  MSdecine  de  Nancy,  16  juin  1915,  fasc.  6,  p.  452. 

Spillmann  et  Sartory. — Traitement  du  tetanos  confirme  par  le 
s^rum  antitetanique  et  le  chloral,  Acad,  de  Midecine,  2  et  8  mars 
1915. 


BIBLIOGRAPHICAL  INDEX  935 

Talamon  et  PoMMAY. — Traitement  du  tetanos  par  I'acide  phenique. 

Presae  midicaU,  19  novembre  1914. 
TuFFiEB. — Contribution  a  la  chimrgie  de  guerre.     Acad,  de  Medecine, 

13  octobre  1914. 
Vatt.labd. — Acad,  de  MSdecine,  23  novembre  1915. 
VaIjEtte. — A  propos  d'lin  cas  de  t6tano8  retarde.     Lyon  Ghirurgical, 

octobre  1915,  p.  427. 
Vallas. — XF«  Gongres  de  Chimrgie,  Paris,  20  octobre  1902. 
Vautbin. — Quelques  considerations  sur  le  tetanos.     C.  R.  Societe  de 

MSdecine  de  Nancy,  23  juin  1913,  fasc.  7,  p.  550. — Anaphylaxie 

dans  le  tetanos.     C.  R.  Societe  de  Medecine  de  Nancy,  26  mai 

1915,  p.  469. 
Verhaeghe. — Plaie  pen6trante  de  1'  abdomen,  laparotomie  retardee. 

Anastomose     intestinale    latero-laterale.     Involution    vers    la 

gu6rison.     Mort  huit  jours   plus  tard  par   tetanos.     Reunion 

Medicate  Vie  ArmSe,  20  octobre  1915. 
Vincent    et    Welhelm. — Un    cas    de    tetanos    localise.     Reunion 

Medico-Ghirurgicale  Ve  Armee,  27  novembre  1915. 
Walther. — Notes  sxir  1' evolution  et  la  prophylaxie  du  tetanos  chez 

les  blesses  de  guerre.     Bulletin  Acad,  de  Medecine,  29  septembre 

1914 ;     Presae    Medicale,    8    octobre    1914. — Cyphose    dorsale 

angulaire  k  type  pottique  au  cours  d'une  attaque  de  tetanos. 

Society  de  Chimrgie,  7  juillet  1915. 
Weiss  et  Gross. — Notes  de  Chimrgie  de  guerre.     SociStS  Chirurgi- 

cale,  27  Janvier  1915. 
Worms.  — Du  tetanos  bulbo-paraly tique.     Theae  de  Lyon,  1 90  5- 1 90  6, 

No.  16. 


SECTION  V 

MALARIA 


MALARIA    IN    MACEDONIA 

Chapter  I 

PARASITOLOGY 

Malaria  is  due  to  the  development  in  the  organism 
of  a  protozoon  discovered  by  Laveran,  which  is 
inoculated  by  the  bite  of  the  Anopheles  mosquito, 
and  by  the  female  Anopheles  exclusively.  This 
protozoon  assumes  three  very  different  types, 
which  most  parasitologists  consider  nowadays  as 
three  distinct  species,  the  Plasmodium  vivax,  the 
agent  of  benign  tertian  ;  the  Plasmodium  malarice^ 
the  agent  of  quartan  fever ;  and  the  Plasmodium 
prcecox  or  falciparum,  the  agent  of  tropical  fever, 
aestivo-autumnal  fever  or  malignant  tertian. 

Although  they  form  distinct  species,  these  three 
parasites  should  be  grouped  together  under  the 
generic  name  of  malarial  ha?matozoa,  because 
they  present  similar  biological  and  developmental 
characters  and  pathogenic  properties,  and  are 
affected  by  the  same  therapeutical  agent,  quinine. 
They  can  only  be  inoculated  into  man  by  the  bite 
of  the  female  Anopheles,  in  whose  organism  they 
undergo  an  identical  evolution  ;  after  being  intro- 
duced by  the  saliva  of  the  mosquito  they  reach 
and  penetrate  the  red  corpuscles  and  develop  in 
the  form  of  a  small  amoeba,  which  is  first  of  all 
round  (schizont)  and  then  irregular  owing  to  the 

939 


940  MALARIA  IN  MACEDONIA 

pseudopodia  protruded  from  its  protoplasm 
(amoeboid  body).  They  increase  in  size  at  the 
expense  of  the  corpuscle  which  they  have  invaded. 
After  some  time  the  parasite  divides  by  repeated 
segmentation  of  its  nucleolus ;  it  then  forms  a 
rounded  mass,  in  the  centre  of  which  is  a  collec- 
tion of  pigment,  constituted  by  the  union  of  ten, 
twelve,  or  sixteen  nucleoli,  arranged  like  rosettes 
round  the  centre  and  each  surrounded  by  a  thin 
zone  of  protoplasm  (rosette  body).  This  process 
of  division  of  the  parasites  is  called  schizogony. 
When  the  rosette  body  is  mature  it  becomes  dis- 
sociated. Each  of  the  nucleated  elements  which 
constituted  it,  after  being  set  free  by  the  rupture 
of  the  red  corpuscle,  is  discharged  as  a  merozoite 
into  the  circulating  blood,  where  it  fastens  upon  a 
red  corpuscle,  becomes  transformed  in  turn  into 
a  schizont,  as  a  merozoite  attached  to  a  red 
corpuscle  is  called,  then  into  an  amoeboid  body, 
and  finally  into  a  rosette  body,  the  cycle  continu- 
ing in  the  same  way. 

The  haematozoon  also  gives  rise  to  certain 
elements,  whose  role  is  all  important,  known  as 
gametes  (sexual  forms).  These  elements  are  formed 
at  the  expense  of  the  schizonts  and  amoeboid  bodies, 
which  instead  of  dividing  into  rosette  bodies  become 
transformed  into  a  body  which  is  either  rounded 
(in  Plasmodium  vivax  and  Plasmodium  mdlarioe)  or 
falciform  (in  Plasmodium  falciparum),  and  is  soon 
set  free  in  the  circulation.  This  body,  which  is  the 
gamete,  possesses  two  extremely  important  biologi- 
cal properties.  In  the  first  place,  it  is  responsible 
for  the  chronicity  of  malaria  in  the  human  organism 


PARASITOLOGY 


941 


and,  secondly,  it  is  the  cause  of  the  persistence  of 
malarial  endemics  throughout  the  globe. 


FlO.  1. — Evolution  of  the  Plasmodium  falciparum.  Est.,  Stomacli 
of  the  Anopheles;  gl.  sal.,  sahvary  glands  (after  Brumpt). 
1,  2,  3.  Schizonts.  4.  Amoeboid  body,  4'".  Rosette  body. 
6,  6.  Gametes.     7-11.  Fecundation.     12.  Zygote.     15-18.  Oocyst. 

The  gamete  is  extremely  resistant  to  quinine  ; 
while  the  vegetative  forms   (schizonts,  amoeboid 


942  MALARIA  IN  MACEDONIA 

bodies,  and  rosette  bodies)  are  destroyed  by  the 
drug,  the  gametes  may  persist  in  the  organism 
for  months  or  years.  Now  under  certain  conditions 
when  the  organic  resistance  gives  way,  under  the 
influence  of  fatigue  or  meteorological  circumstances, 
the  gametes,  which  had  hitherto  remained  quiescent 
like  parasitic  cysts,  begin  to  divide  and  by  multi- 
plication of  their  nucleus  give  rise  to  a  rosette 
body,  the  rupture  of  which  sets  free  the  merozoites. 
The  latter  at  once  attack  the  red  corpuscles,  in- 
crease in  size  and  number,  and  the  ordinary  cycle 
of  schizogony  is  reproduced.  This  special  process 
of  segmentation  of  the  gametes  is  called  retro- 
gressive schizogony  or  "  parthenogenesis  of  the 
gametes."  This  is  the  ordinary  process  in  re- 
lapses of  malaria.  It  can  easily  be  understood 
that  as  long  as  these  special  elements  persist  in 
the  organism,  the  patient  is  exposed  to  a  relapse, 
and  it  is  in  this  sense  that  it  may  be  said  that  the 
gamete,  and  the  gamete  only,  keeps  up  the  chron- 
icity  of  the  disease. 

On  the  other  hand,  when  a  female  Anopheles 
has  sucked  up  the  blood  of  a  malarial  individual, 
if  the  blood  contains  only  the  vegetative  forms 
of  the  ha?matozoon  (schizonts,  amoeboid  bodies, 
and  rosette  bodies),  these  forms  are  destroyed  in 
the  organism  of  the  mosquito.  If,  on  the  con- 
trary, the  blood  contains  gametes,  not  only  do 
they  persist  in  the  body  of  the  Anopheles,  but 
they  multiply  in  it  to  such  an  extent  that  in  a 
short  time  the  salivary  glands  of  the  mosquito 
are  invaded  by  an  enormous  quantity  of  para- 
sites, and  if  it  bites  a  healthy  man,  it  will  inevit- 


PARASITOLOGY 


943 


ably  inoculate  the  disease.  Without  gametes, 
therefore,  there  would  be  no  endemic  of  malaria. 
The  development  of  the  gametes  within  the 
Anopheles  offers  a  very  peculiar  character,  which 


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Fig.  2. — Relation  of  PL  vivax  to  PI.  falciparum  observed  during 
the  period  of  a  year  in  the  Army  Laboratory. 

we  will  describe  in  a  few  words.  Among  the 
gametes  absorbed  by  the  Anopheles  in  the  blood 
of  the  malarial  individual,  some,  viz.,  the  macro- 
gametes,  behave  like  female  elements,  while  others, 
viz.,  the  microgametes  (or  micro-gametocytes),  behave 


944 


MALARIA  IN  MACEDONIA 


like  male  elements.  The  latter  protrude  at  their 
periphery  a  series  of  filaments  ending  in  a  swollen 
free  part  containing  chromatin.  These  filaments 
or  flagellated  bodies  become  separated   from  the 


9^^ 


SOO 


D£t      JAMir     FEV.    MARS   AvB'L     MAi   -JO'*-    -VllUI   AOUT     StPT.     OCt,      NOV.    0£C      JANV. 


Fig.  3. — Proportion  of  the  different  forms  of  PI.  vivax  (Army 
Laboratory). 

microgametes,  and  make  their  way  by  movements 
resembling  those  of  spermatozoa  towards  the 
macrogamete  which  one  of  them  succeeds  in 
fecundating.  After  fecundation,  the  ovum 
(ookinete    or    zygote)    thus     formed,    becomes    an 


PARASITOLOGY  945 

elongated,  mobile  element,  which  passes  through 
the  stomach  wall  of  the  mosquito  and  becomes 
lodged  in  the  muscular  coat  of  the  stomach,  when 
it  increases  in  size  and  becomes  surrounded  by  a 
resistant  zone.  It  is  now  an  oocyst.  This  oocyst, 
which  is  derived  from  the  fertilized  gamete,  be- 
comes the  seat  of  an  active  process  of  segmenta- 
tion ;  its  nucleolus,  which  is  primarily  single, 
becomes  divided  a  very  large  number  of  times 
(up  to  10,000).  A  thin  band  of  protoplasm 
gathers  round  each  of  the  nucleoli,  and  the  oocyst 
is  thus  filled  with  10,000  closely-packed  daughter 
elements,  each  of  which  is  a  sporozoite.  The 
oocyst  on  reaching  maturity  ruptures,  the  sporo- 
zoites  escape,  and  reach  the  salivary  glands  of  the 
mosquito,  the  bite  of  which  will  inoculate  them 
into  human  blood. 

The  hsematozoon  of  malaria  thus  presents  two 
sharply- separated  phases,  one  of  sexual  life, 
which  takes  place  solely  in  the  organism  of  the 
female  Anopheles,  the  other  of  asexual  life,  which 
occurs  in  the  human  organism.  In  the  latter 
reproduction  of  the  parasite  takes  place  in  two 
ways  (1)  by  schizogony,  i.e.  the  formation  of  rosette 
bodies  at  the  expense  of  the  adult  vegetative 
forms ;  (2)  by  parthenogenesis,  or  the  formation  of 
rosette  bodies,  at  the  expense  of  the  unfertilised 
gametes.^ 

*  Hitherto  the  process  has  been  seen  only  in  the  female 
gametes  or  macrogametes.  P.  Armand-Delille,  G.  Paisseau, 
and  H.  Lemaire.  Note  sur  les  constatations positives  d'hematozoaires 
de  bacterioiogie  de  I'Armee  de  I'Oment  pendant  Pannee  1916. 
Bull,  de  la  Sac.  de  Path,  exotique.     Meeting  held  April  11,  1917. 


94  H 


MALARIA  IN  MACEDONIA 


The  cha})ter  on  microscopical  diagnosis  contains 
a  description  of  the  characters  whereby  each  of 
the  three  varieties  of  the  hsematozoa  can  be  recog- 


:?i4 


2oo 


i8o 


Al      JupN     juiLltT    AOUT        StPT.     OCT.        fjQV       DtC       JiNV. 


Fig.  4. — Pioportion  of  the  different  forms  of  PL  falciparum  (Army 
Laljoratory). 

nized  in  the  blood  of  the  patient  in  their  various 
stages  of  development. 

It  seems  important  to  mention  liere  that  of  these 
three  })arasites  the  Plasmodium  malarice,  the 
agent  of  quartan  fever,  is  absolutely,  exceptional 
in  Macedonia,  where  investigations  made  in  differ- 


I 


PARASITOLOGY  947 

cut  laboratories  have  shown  it  to  be  present  in 
only  ten  cases  ;  the  Plasmodium  falciparum,  the 
agent  of  tropical  fever,  represents  in  summer  (July- 
November)  more  than  85  per  cent,  of  the  cases 
of  malaria  ;  while  the  Plasmodium  vivax,  the  agent 
of  benign  tertian,  is  rare  in  summer,  occurring  in 
only  15-17  per  cent.,  and  becomes  very  predom- 
inant from  December  to  July. 

The  overwhelming  majority  oi'  mos([uitoes  in 
Macedonia  consist  of  the  Anopheles  maculipennis 
or  claviger  ;  A.  hifurcatus,  Pyretophorus  superpictus 
and  Myzorhynchus  pseudopictus  have  been  caught 
much  less  frequently.  The  quantity  of  Anopheles 
reaches  absolutely  extraordinary  proportions  in 
some  regions  of  Macedonia,  it  being  possible  to 
catch  hundreds  of  dangerous  mosquitoes  in  a  few 
hours. 

This  enormous  number  of  Anopheles,  to  which 
Niclot,  the  principal  medical  officer,  has  drawn 
attention,  possesses  special  interest.  It  is  this 
factor  which  to  a  great  extent  accounts  for  the 
severity  of  malaria  in  Macedonia.  In  a  country 
where  there  are  innumerable  carriers  of  the  virus, 
both  in  the  civil  population  and  among  the  troops, 
a  very  large  number  of  Anopheles  are  infected. 

The  result  is  that  men  are  exposed  to  inocula- 
tions of  the  malarial  virus  several  times  a  day, 
and  this  accumulation  of  repeated  doses  gives  rise 
to  a  disease  which  is  at  once  more  severe  and  more 
resistant  to  quinine.  Permanent  and  ubiquitous 
reservoirs  of  the  virus,  an  exceptionally  large 
quantity  of  the  Anopheles,  and  the  malignant 
nature    of   the    parasite    inoculated    {Plasviodium 


948  MALARIA  IN  MACEDONIA 

falciparum),  represent  the  three  principal  factors 
of  gravity  in  a  malarial  endemic  in  Macedonia. 
Deterioration  of  the  inoculated  subject,  which  is  a 
necessary  consequence  of  the  conditions  imposed 
on  the  troops  as  the  result  of  war,  is  naturally  to 
be  added  to  the  factors  already  mentioned. 


Chapter  II 

CLINICAL  STUDY 

During  the  first  months  of  its  course  in  a  hitherto 
unaffected  subject,  malaria  is  not  manifested  by 
tertian,  quartan,  or  quotidian  intermittent  par- 
oxysms, but  by  febrile  attacks  of  very  different 
types,  which  constitute  as  a  whole  primary 
paludism.  This  is  clearly  brought  out  in  some 
textbooks  on  tropical  medicine,  especially  that 
by  Grail.     We  shall  describe  successively  : — 

1.  A  primary  paludism,  which  dates  from  the 
time  of  infection  until  the  appearance  of  the 
intermittent  paroxysms. 

2.  A  secondary  paludism,  characterized  by  frank 
intermittent  and  well-disciplined  attacks,  which 
we  have  chiefly  observed  in  winter  and  the  begin^ 
ning  of  spring. 

Primary  paludism  includes  several  phases.  The 
first  phase  is  called  the  invasion,  which  commences 
ten  to  fifteen  days  after  inoculation,  during  which 
the  patient  usually  presents  a  febrile  syndrome  of 
relatively  short  duration. 

Then,  as  a  rule,  there  occurs  a  period  of  apyrexia, 
of  variable  duration,  during  which  the  patient 
appears  to  have  recovered.  But  the  recovery  is 
only  apparent,  as  the  patient  for  several  months 
will  present  a  series  of  febrile  attacks  of  various 

949 


950  MALARIA  IN  MACEDONIA 

types,  which  constitute  as  a  whole  the  second  phase, 
or  ijhase  of  relapses  and  second  attacks. 

This  in  turn  is  succeeded  by  secondary  paludism, 
in  which,  in  addition  to  frank  intermittent  attacks, 
we  shall  describe  certain  manifestations  which 
only  occur  in  the  subjects  of  prolonged  malarial 
intoxication. 

In  addition  to  malaria  of  normal  evolution  we 
shall  have  to  describe  masked  and  incomplete 
forms.  It  is  obvious  that  in  this  short  study,  and 
even  in  a  more  didactic  description,  a  certain 
number  of  atypical  and  abnormal  forms  liable  to 
be  met  with  in  practice  will  have  to  be  passed  over. 

These  are  the  cases  which  can  only  be  identified 
by  haematological  examination. 


Chapter  III 

SYNDROMES  OF  THE  FIRST  INVASION  OF 
PRIMARY  PALUDISM 

The  phenomena  characterizing  the  period  of  the 
first  invasion  of  primary  paludism  generally  assume 
the  clinical  appearance  of  febrile  gastric  derange- 
ment. This  is  the  syndrome  which  we  have 
observed  in  subjects  who  have  recently  landed  ;  it 
sometimes  occurs  less  than  three  weeks  after  their 
arrival  in  the  malarial  region.  It  is  also  by  far 
the  commonest  manifestation  of  malaria  at  the 
onset  of  an  epidemic  in  the  second  part  of  June  ; 
that  is  to  say,  in  the  month  following  the  hatching 
of  the  female  Anopheles.  This  febrile  gastric 
derangement  may  assume  a  severe  form,  simulating 
typhoid  fever,  or,  on  the  contrary,  remain  very 
slight  and  only  be  manifested  by  what  is  generally 
known  as  a  feverish  attack. 


1.  Syndrome  of  Febrile  Gastric  Derangement 

Durmg  a  short  prodromal  period  of  three  or  four 
days  before  presenting  any  fever,  the  patient  suffers 
from  vague  malaise,  headache,  and  a  feeling  of 
muscular  fatigue,  and  the  appetite  is  lost.  He 
generally  attributes  these  symptoms  to  the  heat 
or  to  overwork.     Often  even  he  does  not  pay  any 

951 


952 


MALARIA  IN  MACEDONIA 


attention  to  them,  and  the  affection  appears  to 
start  suddenly  with  sHght  shivering,  a  rise  of 
temperature,  or  a  sensation  of  heat.  The  patient 
then  complains  of  severe  aching  in  all  his  limbs 
and  of  lumbar  and  epigastric  pain.  The  headache 
begins  in  the  morning  and  gets  worse  towards  the 


s.amff—iir-  ^t 


Fig.  5. — Febrile  gastric  derangement  of  the  first  invasion  (Dr 
Abrami). 

evening.  There  is  absolute  anorexia,  the  tongue 
is  dirty  and  coated,  vertigo  and  nausea  are  constant, 
and  vomiting  is  frequent.  Constipation  is  the  rule, 
but  sometimes  a  little  diarrhoea  of  indefinite 
character  may  be  noted. 

Nothing  definite  is  found  on  examination  of  the 


FIRST  INVASION  OF  PRIMARY  PALUDISM  953 

various  organs  ;  the  respiratory  system  is  normal, 
the  abdomen  is  not  distended  or  tender,  and  the 
liver  is  not  enlarged,  but  the  spleen  is  undoubtedly 
increased  in  size.  The  splenomegaly,  however,  is 
slight,  similar  to  that  found  in  typhoid  fever. 
By  hooking  the  fingers  under  the  left  costal  margin 
it  is  often  possible  to  feel  the  lower  pole  of  the  organ, 
which  is  tender  on  pressure.  The  patient  also 
complains  of  a  painful  dragging  or  stitch  in  the 
splenic  region.  The  temperature  reaches  100*4°  F. 
on  the  first  day,  and  for  three,  four,  or  even  five 
days  keeps  at  a  level  of  101*2°  or  102*2°,  usually 
with  oscillations  of  not  more  than  a  degree.  Defer- 
vescence takes  place,  as  a  rule,  by  lysis*in  two  or 
three  davs  at  most,  even  without  the  administration 
of  quinine,  and  occurs  without  any  of  the  ordinary 
critical  phenomena  of  the  ague  fit. 

If  the  temperature  be  taken  every  hour  it  will 
be  found  that  the  daily  acme  takes  place  at  the 
beginning  of  the  afternoon.  The  pulse  follows  an 
almost  parallel  path  with  that  of  the  fever,  but 
increases  a  little  more  rapidly  in  the  course  of  the 
day. 

It  can  readily  be  understood  that  with  symptoms 
of  this  kind  the  nature  of  the  affection  is  often 
unrecognized,  and  is  regarded  as  a  mere  febrile 
gastric  derangement,  a  paratyphoid  fever,  or  a 
typhoid  ffever  attenuated„by  vaccination. 

The  difficulty  may  be  further  increased  owing 
to  the  co-existence  of  an  affection  which  is  also 
prevalent  in  summer  in  Macedonia,  viz.,  Mediter- 
ranean dengue,  or  three  day  fever.^ 

*  Vide  Sarrailhe,  Arniand-Delille,  and  Ch..Richet  fils,  La  dengue 


954  MALARIA  IN  MACEDONIA 

But  the  more  sudden  onset,  intensity  of  the 
prostration,  cervical  and  lumbar  rachialgia,  pains 
in  the  bones  of  the  limbs,  rapidity  of  course, 
absence  of  vomiting  and  splenomegaly,  and  occas- 
sionally  the  characteristic  eruption  are  diagnostic 
features,  in  addition  to  the  profound  asthenia  met 
with  in  convalescence,  which  is  surprising  in  so 
short  a  disease. 

The  patient  leaves  hospital  apparently  cured, 
but  if  he  has  not  been  given  sufficient  quinine,  he 
will  shortly  afterwards  show  clinical  manifestations 
characteristic  of  the  disease. 


2.  Malarial  continued  Fever  of  Typhoid 
character 

The  continued  fever  of  the  first  invasion  may 
assume  a  typhoid  form.  After  a  few  days'  malaise, 
the  patient  suddenly  feels  that  his  condition  is 
getting  worse  ;  he  is  seized  with  shivering,  intense 
fever,  headache,  generalized  aching,  and  lumbar 
and  epigastric  pain.  He  is  in  a  state  of  profound 
asthenia,  exhausted  and  prostrate ;  his  sleep  is 
restless  and  interrupted  occasionally  by  mild 
delirium.  He  has  frequent  mucous  vomiting,  a 
constant  st^te  of  nausea,  a  thickly-coated  tongue, 
and  slight  epistaxis. 

ntediterrant'enne  on  fievre  de  tru'is  joum.  C.  R.  Acad,  de  M6d  ,  Oct. 
191.5. 

Sarraillic',  Dengue  ei  fiivre  de  trois  jours.  Bull,  de  la  Soc.  de 
Path,  exoiique,  Dec.   I.'],  19H). 

Arniand-Delille.  Nnteti  fur  le.s-  principaur  cur(icti:n:s  de  la 
denyue  mcdderrunetiine.      Hull.  Soc.  Med.  des  Hup.,  Nov.  1916. 


FIRST  INVASION  OF  PRIMARY  PALUDISM   955 

On  examination  it  will  be  found  that  there  is 
little  involvement  of  the  thoracic  or  abdominal 
organs.  The  abdomen  is  not  distended  or  re- 
tracted, and  diarrhoea  is  exceptional  ;  thi  liver, 
however,  reaches  a  little  below  the  false  ribs,  and 
is  slightly  tender  on  pressure  ;  the  spleen  under- 
goes some  hypertrophy,  w^hich  somewhat  exceeds 
that  found  in  typhoid  fever.  It  is  on  a  level  with 
the  costal  margin,  and  is  tender  on  palpation. 
The  patient  complains  spontaneously  of  a  stitch 
or  a  feeling  of  weight  in  the  left  hypochondriuni. 
Examination  of  the  respiratory  organs  is  completely 
negative.  The  urine  as  a  rule  contains  no  albumin, 
and  has  merely  the  character  of  all  febrile  urine. 

The  pulse  is  quickened  and  very  compressible, 
the  arterial  tension  being  definitely  lowered.  Its 
frequency  is  parallel  with  the  temperature.  The 
fever,  which  at  the  very  first  had  risen  to  103*2° 
or  even  104*8°,  keeps  at  this  high  level  for  a  fort- 
night or  even  three  weeks.  On  taking  the  tempera- 
ture hourly  it  will  be  found  that  it  begins  to  rise 
in  the  morning,  reaches  its  acme  at  the  beginning 
of  the  afternoon,  and  falls  to  the  lowest  level  in 
the  first  part  of  the  night. 

The  temperature  curve  regularly  presents  two 
breaks  or  relative  defervescences,  one  on  the  fifth 
or  sixth  day,  and  the  other  on  the  eleventh  or 
twelfth  day.  In  moderate  cases  defervescence  is 
sudden  and  final  on  the  twelfth  day  ;  in  serious 
cases  a  recrudescence  takes  place,  and  the  course 
of  the  fever  becomes  prolonged,  lasting  even  for  a 
third  week. 

Frequently,    even    in    the    severest    forms,    the 

B 


956 


MALARIA  tN  MACEDONIA 


continued  fever  gives  way  to  a  series  of  quotidian 
attacks,  with  large  oscillations,  of  which  the  lowest 


Fig.  6. — Continued   malarial  fever  with  a  typhoid  course   (Dr 

Gassin). 

readings  are  about  99*2°  and  the  highest  above 
104*0°  F.     This  daily  intermittent  fever  lasts  for 


FIRST  INVASION  OF  PRIMARY  PALUDISM  957 

some  days,  and  is  followed  by  a  definitive  fall  of 
temperature. 

The  typhoid  form  of  the  first  invasion  of  paludism 
might  easily  be  confounded  with  a  true  typhoid 
fever,  but  the  rarity  of  abdominal  symptoms,  the 
absence  of  any  pulmonary  manifestations,  and  the 
special  temperature  chart  are  sufficient  to  enable 
the  medical  man  who  is  on  his  guard  to  make  a 
correct  diagnosis,  which  will  be  confirmed  by  a 
negative  typhoid  blood-culture  and  a  positive 
result  as  regards  the  haematozoon.  This  severe 
form  of  malarial  continued  fever  occurs  among 
subjects  who  are  profoundly  infected  by  the 
Plasmodium  falciparum,  their  blood  being  rich  in 
small  annular  schizonts. 


3.  Attenuated  Form  of  Invasion,  Febrile 
Malaise,  and  Fatigue 

The  symptoms  of  the  first  invasion  may  be 
much  more  insidious  than  in  the  two  forms  just 
described.  The  patient  is  not  obliged  to  take  to 
bed  ;  for  a  period,  which  is  usually  fairly  short, 
but  which  may  vary  from  four  to  six  days,  He 
merely  has  a  feeling  of  abnormal  fatigue  and 
asthenia,  which  he  attributes  to  the  summer  heat, 
for  the  epidemic  is  always  at  its  worst  in  the  hot 
season. 

In  addition  to  his  unusual  sense  of  fatigue, 
which  chiefly  occurs  in  the  early  hours  of  the 
afternoon,  and  is  accompanied  by  somnolence, 
there  is  considerable  digestive  disturbance,  anorexia, 
and  a  state  of  nausea.     The  patient  also  suffers 


958  MALARIA  IN  MACEDONIA 

from  headache,  which  is  increased  by  the  shghtest 
physical  or  intellectual  effort,  and  often  shows  a 
daily  exacerbation  about  midday.  Lastly,  in 
contrast  with  the  somnolence  during  the  day, 
there  is  insomnia  at  night.  If  the  patient  is  a 
careful  observer,  he  will  notice  transient  febrile 
attacks,  characterized  by  slight  shivering,  accom- 
panied by  short  spells  of  heat  and  then  of  slight 
perspiration.  The  malaise  is  almost  always 
followed  by  a  feeling  of  well-being  at  the  end  of 
the  day.  The  symptoms  are  sometimes  sufficiently 
pronounced  to  necessitate  temporary  exemption 
from  military  duties,  but  often  they  are  so  slight 
that  they  escape  notice. 

The  three  syndromes  which  we  have  just 
described  are  much  the  most  usual  form  of  con- 
tinued fever  of  the  first  invasion  of  malaria. 
Patients,  however,  are  sometimes  seen  who  are 
suffering  from  malaria,  though  their  fever  is  of  an 
entirely  different  character,  viz.,  a  fever  of  inter- 
mittent type  accompanied  by  the  same  symptoms 
of  gastric  derangement.  The  fever  shows  great 
oscillations,  the  lowest  temperatures  being  about 
98'6°,  and  the  highest  sometimes  exceeding  104°  F. 
The  attacks  recur  daily,  constituting  quotidian 
intennittent  fever .  The  patient  complains  of  intense 
headache,  insomnia,  pains  in  the  limbs,  and  lumbo- 
epigastric  pain.  He  is  depressed  and  asthenic. 
His  tongue  is  dirty  ;  he  suffers  irom  nausea, 
and  there  is  frequent  vomiting  of  mucus.  The 
symptoms  show  an  exacerbation  at  the  time  of 
daily  rise  of  temperature. 

But,    according    to    the    opinion    of    numerous 


FIRST  INVASION  OF  PRIMARY  PALUDISM  959 

writers,  this  quotidian  intermittent  fever  is  only 
apparently  a  manifestation  of  the  first  invasion, 
since  on  careful  inquiry  it  will  always  be  found 
that  the  patient  had  previously  suffered  from 
malaria  or  a  febrile  attack,  constituting  the  true 
stage  of  invasion  which  had  escaped  notice. 


Chapter  IV 

PERIOD  OF  RELAPSES  AND  SECOND 
ATTACKS  IN  PRIMARY  PALUDISM 

After  the  termination  of  the  period  of  invasion, 
malaria  enters  into  a  silent  phase  in  which  the 
patient  appears  cured,  even  if  he  has  been  in- 
sufficiently treated;  this  period  sometimes  lasts 
from  two  to  four  weeks,  rarely  longer.  Most  of 
the  patients  return  to  their  depot ;  they  may  even 
have  rejoined  their  unit  when  they  again  develop 
symptoms  which  may  assume  a  considerable 
gravity.  These  symptoms  are  due  to  a  relapse, 
or  second  attack  of  paludisni.  In  the  case  of 
relapse  there  is  no  fresh  infection,  but  the  patient's 
organism  has  not  been  sterilized  by  the  treatment  ; 
he  remains  a  gamete  carrier,  and  a  renewed  growth 
of  the  parasites  takes  place  of  varying  periodicity 
and  intensity,  giving  rise  to  fresh  manifestations 
of  the  disease. 

In  the  case  of  a  second  attack,  the  subject  who 
has  remained  in  an  infected  country  and  exposed 
to  contagion  contracts  successive  and  frequently 
intense  reinfections.  He  then  presents  fresh 
malarial  manifestations,  which  are  generally  severe. 

Some  writers  have  wanted  to  make  a  distinction 

between  a  relapse  and  a  second  attack,  based  on 

cUnical  grounds. 

960 


SECOND  ATTACKS  IN  PRIMARY  PALVDISM  9<n 

As  regards  malaria  in  Macedonia,  it  appears  to 
us  to  be  impossible  to  establish  such  a  distinction 
which,  it  may  be  said,  possesses  no  practical  im- 
portance, as  the  treatment  should  be  the  same  in 
both  conditions. 

The  symptoms  which  indicate  relapses  and 
second  attacks  do  not  merely  present  the  character 
of  general  infection  peculiar  to  the  syndromes  of 
the  first  invasion.  The  viscera  are  more  profoundlv 
affected,  and  some  especially  so,  viz.,  the  haemato- 
poietic organs  (spleen  and  bone  marrow),  the  liver, 
alimentary  canal,  and  suprarenal  capsules.  The 
other  systems,such  as  the  respiratcry,circulatory,and 
nervous  systems,  may  be  involved  to  some  extent. 

The  disease  may  assume  different  clinical  forms 
as  the  result  of  the  multiple  localizations  of  the 
infection  and  their  various  combinations. 

Sometimes  the  febrile  manifestations  predomin- 
ate, giving  rise  to  a  general  disease  of  a  typhoid 
character.  In  other  cases,  on  the  contrary,  the 
visceral  symptoms  become  most  prominent,  and 
the  patient  seems  to  be  suffering  from  an  acute 
visceral  affection. 

Under  certain  conditions  the  general  infection 
is  so  intense  and  violent  that  it  causes  profound 
changes  in  certain  essential  organs,  and  gives  rise 
to  a  dramatic  syndrome  called  the  pernicious  attack. 
But,  fortunately,  malaria  does  not  always  show 
such  pronounced  symptoms,  and  its  evolution  is 
not  always  so  serious.  It  may  only  be  revealed 
by  attenuated  symptoms  of  infection,  or  very 
slight  febrile  attacks,  when  it  is  known  as  defaced 
'paludism. 


962  MALARIA  IN  MACEDONIA 

The  fever  may  even  escape  notice,  and  only 
localized  lesions  indicating  an  organic  affection  are 
observed.     This  constitutes  masked  paludism. 

For  the  sake  of  clearness,  we  shall  begin  by 
describing  the  principal  types  of  the  temperature 
curve,  and  we  shall  then  study  the  visceral  syn- 
dromes, pernicious  attacks,  defaced  paludism  and 
masked  paludism. 

1.  The  Temperature  Curve  in  the  Period  of 
Relapses  and  Second  Attacks 

On  reaching  the  period  of  relapses  and  second 
attacks  after  the  silent  phase,  in  which  he  might 
be  supposed  to  be  cured,  the  patient  will  present  a 
series  of  febrile  attacks  of  different  types,  and 
various  forms  of  fever  may  be  found  in  the  same 
subject,  either  succeeding  one  another  immediately 
without  an  interval  of  apyrexia,  or  separated  by  an 
afebrile  period  of  varying  duration. 

The  types  of  fever  which  we  have  most  frequently 
observed  are  the  following  : — 

(1)  Remittent  continued  fever. 

(2)  Quotidian  intermittent  fever. 

(3)  Tertian  attacks  of  a  somewhat  special 
character. 

(4)  An  apparently  irregular  fever  impossible  to 
classify. 

(1)  Remittent  continued  fever  is  of  the  same 
type  as  that  usually  found  in  the  period  of  invasion 
and  which  we  have  already  described.  In  this 
form,  in  which  the  temperature  keeps  at  a  high 
level,    with    very    slight    oscillations,    the    daily 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  9G3 

remissions    being    inconsiderable,    the    curve    fre- 
quently presents  two  typical  breaks  towards  the 


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some   ascending  oscillations   and   the   final   fall   of 


964 


MALARIA  IN  MACEDONIA 


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SECOND  ATTACKS  IN  PRIMARY  PALUDISMmr, 


temperature,  which  occurs  at  the  end  of  the  first, 
second,  or  third  week,  usually  takes  place  by  lysis. 

(2)  Quotidian  intermittent  fever  is  manifested 
by  quotidian  attacks  with  large  oscillations  re- 
curring for  several  consecutive  days  ;  the  rise  of 
temperature  begins  in  the  morning  ;  at  noon  the 
maximum  tempera- 
ture is  reached,  e.g. 
102-2°,  104°,  and 
even  105-8°  F.,  and 
keeps  at  this  level 
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end  of  the  evening, 
but  is  never  com- 
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mometer generally 
remains  above 
99-4°  F.  Quotidian 
intermittent  fever 
often  begins  sud- 
denly, with  a  rise 
to  104°  F. 

(3)  Isolated  at- 
tacks occur  in  the 
midst  of  a  phase  of  more  or  less  complete  apyrexia. 
The  temperature,  which  in  the  morning  was  often 
below  98-6°  reaches  104°  in  the  first  part  of  the 
afternoon,  and  the  next  morning  defervescence  is 
complete.  The  temperature  may  be  even  sub- 
normal. 

(4)  Attacks    with     a    tertian     grouping. — The 


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966 


MALARIA  IN  MACEDONIA 


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Fig.  11. — Attacks  with  a  tertian  grouping. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  967 

attacks  of  lever  may  be  so  grouped  as  to  give  the 
chart  the  appearance  of  a  fever  of  the  tertian  type. 
The  temperature  curve,  in  fact,  seems  to  be  formed 
by  a  series  of  attacks,  separated  by  a  day  of 
apyrexia.  But  on  closer  examination  it  will  be 
seen  that  the  apyrexia  does  not  last  thirty-six  or 
even  twenty-four  hours,  as  in  the  tertian  fever  of 
the  secondary  period  of  paludism.  It  is  much 
shorter,  and  barely  twelve  hours  after  deferves- 
cence the  fever  returns,  the  reascent  is  rapidly 
progressive,  and  the  maximum  temperature  is 
reached  thirty-six  hours  after  the  minimum  and 
forty-eight  after  the  previous  maximum. 

(5)  Irregular  fever. — Lastly,  in  some  cases  the 
temperature  curve  has  an  irregular  character, 
which  it  seems  impossible  to  analyse  or  classify. 
As  a  matter  of  fact  these  are  often  examples  of 
quotidian  attacks  which  are  not  registered  on 
the  chart  because  the  maximum  temperatures 
occur  at  a  very  different  time  from  that  at  which 
the  temperature  is  usually  taken. 

These  different  types  of  fever  may  succeed  one 
another  without  an  interval  of  apyrexia  ;  thus  a 
remittent  continued  fever  is  often  seen  to  be 
followed  im'mediately  by  a  quotidian  intermittent. 
But  as  a  rule  the  febrile  attacks  are  separated  by 
a  phase  of  apyrexia  of  very  variable  duration. 
In  most  cases  the  apyrexial  periods  are  of  unequal 
length,  so  that  no  periodicity  in  the  return  of  the 
febrile  attacks  can  be  detected  ;  in  a  large  number 
of  cases,  however,  a  relative  periodicity  may  be 
observed.  This  generally  happens  in  the  case  of 
attacks  occurring  singly  or  in  pairs  every  six  or 


968  MALARIA  IN  MACEDONIA 

seven  days,  or  every  twelve  or  fourteen  days. 
This  is  known  as  the  septan  or  bi-septan  rhythm  ; 
the  attack  may  even  abort  in  the  second  week, 
and  the  apyretic  period  may  then  last  nearly  a 
month. 

The  temperature  curve  between  the  attacks 
does  not  always  have  the  same  appearance.  After 
the  attack  it  is  not  uncommon  to  find  a  slight 
hypothermia,  the  temperature  being  about  06*8°, 
and  then  in  the  days  preceding  the  following 
attack  it  rises  a  degree.  The  apyrexial  phase, 
therefore,  seems  to  consist  of  two  stages,  the 
first  being  one  of  hypothermia,  which  follows 
defervescence  from  a  febrile  attack,  and  the  second 
one,  in  which  the  temperature  oscillates  about 
98*6°  and  heralds  a  new  attack. 

2.  Syndromes  of  Visceral  Localizations 

These  clinical  syndromes,  though  they  may  vary 
in  their  localizations,  have  always  a  certain  number 
of  features  in  common,  viz.,  anccmia  and  splenome- 
galy on  the  one  hand,  and  asthenia  and  headache 
on  the  other.  These  symptoms  constitute  a 
minimum  syndrome,  which  possesses  considerable 
value  in  the  diagnosis  of  the  nature  of  a  malarial 
phenomenon.  We  shall  begin  this  section  with  a 
description  of  anaemia,  and  will  then  describe  the 
gastro-bilious,  suprarenal,  intestinal,  cachectic,  pul- 
monary, cardio-vascular  and  nervous  syndromes.^ 

'  I'he  reader  must  not  be  surprised  if  he  does  not  find  in  these 
pages  tlie  redundant  and  confusing  terminology  used  by  most 
writers.  We  have  adopted  for  the  sake  of  clearness,  much 
simpler  terms  which  liav6  nevcrtiieless  appeared  to  us  to  corre- 
spond to  the  conceptions  of  contemporary  pathology. 


SECOND  ATTACKS  IN  PRIMARY  PALVDISM  9(>9 

Anemic  Syndbomj:s 

Anaemia.T— Anaemia  ^  is  the  almost  inevitable 
consequence  of  malarial  infection,  and  is  an  early 
symptom  of  it ;  it  occurs,  indeed,  shortly  after 
the  end  of  the  period  of  invasion  at  the  time  of 
the  first  relapse  of  primary  paludism.  When  the 
anaemia  appears,  the  patient  rapidly  assumes  the 
special  facies  which  indicates  its  nature.  The 
face  has  an  earthy  pallor,  with  a  dirty  yellow  tint 
most  marked  on  the  alse  nasi,  ears,  and  labial 
commissures  ;  the  conjunctivae  become  subicteric, 
and  pigment  patches  appear  on  the  forehead  and 
temples  resembling  the  chloasma  of  pregnancy. 
An  earthy  complexion,  however,  is  not  seen  in  all 
anaemic  subjects.  Some  are  only  pale  or  sallow, 
and  their  skin  and  mucous  membranes  have  merely 
lost  their  normal  colour. 

The  anaemic  process,  once  established,  regularly 
progresses,  and  the  clinical  picture  soon  becomes 
complete.  The  pallor  is  accompanied  by  loss  of 
flesh  which  is  usually  considerable,  and  is  a  special 
symptom  differentiating  malarial  anaemia  from  a 
large  number  of  other  anaemic  states.  The  patients 
also  complain  of  a  diminution  of  their  physical 
strength,  of  inability  to  work,  and  pronounced 
asthenia ;  breathlessness  on  exertion  is  fairly 
common  ;  digestive  disturbances  in  the  form  of 
anorexia  and  attacks  of  diarrhoea  are  frequent. 
There  is  also  occasionally  slight  epistaxis  and  a 
little  transient  oedema  over  the  malleoli. 

^  L'aneniie  du  paludisme primaire.    G.  Paisseau  and  H.  Lemaire. 
Bull.  Soc.  Med.  Hop.,  June  1,  1917. 


970  MALARIA  IN  MACEDONIA 

Further  examination  of  the  patient  will  show 
enlargement  of  the  spleen,  which  is  generally  of 
slight  degree,  its  lower  border  being  on  a  level  with 
the  costal  margin  or  reaching  two  fingers'  breadths 
below  it.     The  organ  is  tender  on  pressure. 

The  existence  of  extra-cardiac  and  anaemic 
murmurs  in  the  vessels  of  the  neck  is  also  met 
with  ;  the  pulse  is  of  decidedly  low  tension,  ex- 
ceptionally albuminuria  is  found,  but  it  is  always 
slight  and  transient.  The  anasmia  continues  to 
progress,  and  will  increase  unless  quinine  be 
administered.  On  the  other  hand,  under  the 
influence  of  a  properly  conducted  course  of  quinine 
the  anaemia  may  subside,  the  splenic  enlargement 
diminish,  the  patient  regain  his  weight,  and  his 
general  condition  improve. 

Anaemia  in  primary  paludism  is  not  always  so 
pronounced  as  we  have  just  described  it ;  it  may 
even  be  so  slight  that  it  does  not  attract  the 
practitioner's  attention.  In  such  cases  it  is  only 
revealed  by  examination  of  the  blood. 

Anaemia  in  the  malarial  subject  may  assume 
special  clinical  features  owdng  to  the  import- 
ance of  certain  symptoms  accompanying  it ;  thus 
we  find  descriptions  of  anaemia  with  hydraemia, 
haemorrhagic  anaemia,  splenomegalic  anaemia,  and 
anaemia  with  icterus. 

Anaemia  with  hydraemia. — Anaemia  in  malaria 
is  often  accompanied  by  oedema,  which,  as  a  rule, 
is  slight  and  confined  to  the  malleoli  and  eyelids, 
but  it  is  not  uncommonly  seen  invading  the  lower 
limbs,  and  even  the  scrotum,  in  which  case  there  is 
considerable  puff^iness  of  the  face.     In  exceptional 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  971 

cases  the  oedema  is  accompanied  by  albmninuria, 
which  is  always  very  sHght  and  transient.  The 
duration  of  the  oedema  is  fairly  short,  it  diminishes 
in  a  week  or  a  fortnight,  and  the  hydraemia  becomes 
an  ordinary  anaemia.  The  action  of  diuretics  like 
theobromine  and  a  chloride-free  diet  is  nil,  and  does 
not  appear  in  any  way  to  accelerate  the  absorption 
of  the  oedema. 

Haemorrhagic  anaemia. — A  malarial  patient  with 
anaemia  very  often  shows  some  tendency  to 
haemorrhages,  which  may,  however,  consist  of  only 
very  slight  epistaxis.  But  if  the  condition  gets 
worse,  it  is  not  uncommon  to  see  the  haemorrhages 
increase  in  number.^ 

Sometimes  the  anaemia  is  accompanied  merely 
by  purpura  consisting  of  petechiae  or  of  ecchymoses 
covering  the  lower  limbs  and  trunk. 

In  other  cases  various  haemorrhages  are  associ- 
ated with  this  purpura,  constituting  a  haemorrhagic 
purpura,  in  which  the  patient  presents  obstinate 
epistaxis  requiring  plugging,  haemorrhage  from  the 
gums,  haematuria,  melasna  and  haematemesis,  while 
hypodermic  injections  give  rise  to  haematomata. 

The  anaemia  is  aggravated  by  the  haemorrhagic 
process,  and  some  patients  continue  to  bleed  and 
die  from  loss  of  blood. 

Such  cases  present  all  the  clinical  appearances 
of  progressive  pernicious  ancemia,  viz.,  a  sallow  skin, 
pallor  of  the  mucous  membranes,  slight  oedema  of 
the  lower  limbs,  multiple  haemorrhages,  digestive 
disturbances,  anorexia,  vomiting,  and  diarrhoea. 

^  Syndromes  hemorragiques  dans  le  puludisme.  G.  Paisseau  and 
H.  Lemaire.     BnU.  Soc.  Med.  Hop.,  Oct.  20,  1916. 


972  MALARIA  IN  MACEDONIA 

In  connection  with  this  haemorrhagic  anaemia 
two  points  are  worthy  of  attention.  The  first  is 
the  early  date  of  its  appearance,  which  takes  place 
at  the  very  onset  of  the  period  of  relapses. 
Haemorrhagic  anaemia  is  most  frequent  in  the 
months  of  July  and  August  ;  later  on  malarial 
anaemia  loses  this  haemorrhagic  character.  Secondly, 
judicious  administration  of  quinine  causes  a  definite 
improvement  in  this  tendency  to  haemorrhages, 
though  urgent  cases  may  require  haemostatic 
treatment,  such  as  the  injection  of  a  few  c.c.  of 
horse-serum. 

Splenomegalic  anaemia. — In  some  anaemic 
patients  there  is  considerable  enlargement  of  the 
spleen,  which  may  form  a  veritable  abdominal 
tumour  reaching  down  to  the  umbilicus  or  the 
lumbar  region,  and  with  a  longitudinal  dulness  of 
more  than  thirty  centimetres.  The  enlargement 
of  the  spleen  develops  rapidly,  and  can  be.  made  to 
subside  under  the  influence  of  quinine  treatment, 
but  the  organ  is  slow  in  resuming  its  normal 
«5ize.  There  is  no  other  clinical  feature  character- 
istic of  this  form  of  malarial  anaemia,  and  the 
examination  of  the  other  lymphoid  organs  always 
remains  negative. 

Anaemia  with  icterus. — We  have  seen  that  a 
malarial  patient  with  anaemia  often  has  subicterus 
of  the  conjunctivae  which  is  of  very  slight  degree, 
and  only  accompanied  by  abnormal  pigment  in 
the  urine.  But  it  not  unfrequently  happens  in 
the  course  of  anaemia  for  attacks  of  regl  j?.undice 
to  occur,  in  which  the  patient's  complexion  becomes 
definitely  yellow,  and  the  urine  contains  normal 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM973 

pigment ;  the  stools  then  assume  the  polychohc 
character.  The  attack  of  jaundice,  which  is 
always  of  short  duration,  coincides  with  an  aggra- 
vation of  the  anaemia,  or  succeeds  it.  We  shall 
see  later  that  this  phenomenon  is  often  a  prelude 
to  acute  primary  cachexia. 

Examination  of  the  blood. — The  chief  haemato- 
logical  features  of  the  anaemia  of  primary  paludism 
can  be  easily  described. 

Malarial  anaemia  presents  every  degree  of 
severity  :  the  number  of  the  red  cells  may  some- 
times fall  in  severe  cases  below  a  million.  The 
loss  of  the  red  cells  may  be  very  rapid,  as  the 
patient  in  the  course  of  an  attack  may  lose  more 
than  a  million  in  a  few  days. 

There  is  considerable  inequality  in  the  size  of 
the  red  cells  and  a  tendency  to  increase  in  their 
diameter. 

Malarial  anaemia  does  not  belong  to  the  group 
of  chloro-anaemia,  the  diminution  in  the  amount 
of  the  haemoglobin  not  exceeding  that  of  the 
number  of  the  red  cells. 

There  is  generally  a  diminution  in  the  number 
of  the  white  cells,  constituting  leucopenia.  Instead 
of  7500  to  9000  leucocytes,  the  numbers  fall  below 
6000  and  even  3000.  Any  increase  in  the  number 
of  the  leucocytes  is  very  transitory,  or  is  confined 
to  an  abnormal  form  of  cell. 

The  leucocytic  formula  shows  a  relative  increase 
of  the  mononuclears,  and  therefore  a  diminution 
of  the  polymorphonuclears.  The  polymorpho- 
nuclear count,  instead  of  ranging  between  60  and 
75  per  cent.,  as  it  does  normally,  falls  to  50  and 


974  MALARIA  IN  MACEDONIA 

even  30  per  cent.,  while  the  mononuclear  count 
rises  and  even  exceeds  40  per  cent. 

In  severe  cases,  as  soon  as  the  number  of  the  red 
cells  falls  to  half  the  normal  figure,  elements  of 
the  bone  marrow  appear  in  the  blood,  viz.,  granular 
myelocytes,  and  even  younger  cells  still,  agranular 
myelocytes.  Nucleated  red  corpuscles  are  ex- 
ceptional or  in  very  small  numbers,  even  in  the 
severest  cases. 

Textbooks  state  that  the  blood  in  malaria 
contains  melaniferous  leucocytes,  i.e.  large  mono- 
nuclears stuffed  full  of  malarial  pigment.  As  a 
matter  of  fact  these  cells  are  very  rare  in  the 
circulating  blood  in  the  anaemia  of  acute  paludism. 
They  are  more  frequent  in  secondary  paludism. 
The  presence  of  all  these  haematological  characters 
constitutes  an  excellent  diagnostic  guide  to  the 
malarial  character  of  an  anaemia,  though  it  does 
not  possess  the  same  value  as  the  discovery  of  the 
parasite. 

Gastro-Hepatic  Syndromes 

Gastro-bilious  forms. — The  febrile  manifesta- 
tions of  the  second  phase  of  primary  paludism 
are  very  frequently  accompanied  by  gastric  and 
bilious  syndromes,  which  usually  appear  early. 

The  symptoms  at  first  consist  of  very  severe 
headache,  anorexia,  frequent  bilious  vomiting,  and 
fairly  profuse  diarrhoea.  The  patient  rapidly  de- 
velops subicterus  of  the  conjunctivae  and  even 
of  the  skin,  but  his  urine  does  not  contain  bile 
pigment.     Not  only  does  he  complain  of  lumbar 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  975 

and  epigastric  pain,  but  also  of  profound  asthenia, 
with  an  intense  feeling  of  fatigue.  Examination 
of  the  patient  furnishes  more  information  than  at 
the  period  of  the  first  invasion.  Digestive  dis- 
turbance is  shown  by  a  coated  though  moist 
tongue  and  slight  distension  of  the  abdomen, 
which  may  be  tender  on  palpation.  The  liSfer 
reaches  slightly  below  the  costal  margin.  The 
spleen  is  also  enlarged,  and  to  a  greater  extent 
than  in  typhoid  fever,  sometimes  being  one  to  two 
fingers'  breadths  below  the  false  ribs,  and  palpation 
of  the  two  organs  exaggerates  the  spontaneous 
pain.  The  lungs  are  still  unaffected.  The  heart 
sounds  are  normal,  but  the  pulse  shows  an  accelera- 
tion corresponding  to  the  rise  of  temperature  and 
is  very  compressible  ;  the  arterial  tension  is  low, 
especially  the  minimum  pressure. 

This  gastro-hepatic  syndrome  is  generally  ac- 
companied by  a  continued  fever,  but  the  tempera- 
ture curve  often  shows  certain  peculiarities.  It 
may  be  immediately  preceded  by  a  quotidian 
intermittent  of  five  or  six  days'  duration  ;  defer- 
vescence takes  place  by  lysis,  in  two  or  three 
quotidian  attacks,  which  become  progressively  less 
severe. 

In  grave  cases  prostration  and  adynamia  dom- 
inate the  scene,  and  the  temperature,  which 
throughout  has  been  of  the  continued  type,  rises 
progressively,  and  the  patient  dies  with  hyper- 
pyrexia. 

In  mild  and  moderate  cases  defervescence  is 
accompanied  by  improvement  in  all  the  general 
symptoms. 


976  MALARIA  IN  MACEDONIA 

Form  of  infective  icterus. — In  this  form  also 
the  temperature  curve  consists  of  a  succession  of 
a  continued  fever  and  of  a  quotidian  intermittent. 

The    onset    is    violent ;     the   temperature    rises 
suddenly  to  104°  F.,  the  patient  from  the  first  is 
prostrated  and  plunged  into  a  condition  of  profound 
asthenia.     This  state  of  pronounced  adynamia  is 
interrupted  by  mild  delirium.     Jaundice  develops 
early,  and  rapidly  becomes  darker,  and  the  urine 
contains  bile  pigment.      The  jaundice  is  accom- 
panied by  bilious  vomiting  and  greenish  polycholic 
diarrhoea.     Haemorrhages   frequently    occur,    such 
as  epistaxis,  bleeding  from  the  gums,  purpura,  and 
even  hsematuria  and  melsena.     The  tongue  is  first 
dirty  and  then  becomes  dry  and  shrivelled  ;    the 
abdomen  is  distended  and  tender,  the  face  drawn 
and  pinched,  the  pulse  weak  and  very  compressible. 
The  liver  is  two  or  three  fingers'  breadths  below 
the  false  ribs,  the  spleen  is  as  much  enlarged  if  not 
more,  and  both  organs  are  tender  on  palpation. 
Signs  of  congestion  are  found  at  the  base  of  the 
right  lung.    When  the  general  condition  gets  worse, 
the    adynamia    becomes    pronounced,  the   patient 
grows  livid,  and  dies  from  cardio-vascular  collapse 
with    an    imperceptible    pulse    and    a    subnormal 
temperature.     The   clinical   picture   resembles,    in 
short,  that  of  a  severe  icterus,  but  the  termination 
is  not  always  fatal,  as  this  form  of  icterus  may  end 
in  recovery  by  a  process  resembling  that  of  any 
severe  icterus. 

This  severe  form  of  infective  icterus  is,  however. 

far  from  being  the  most  frequent  type.     During 

the  period  of  a  malarial  epidemic  an  icterus  of  a 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  977 

mild  type  is  much  more  frequently  observed. 
This  icterus  appears  rapidly  after  a  short  prodromal 
stage  of  gastric  derangement,  and  is  accompanied 
by  fever,  which  may  assume  the  continued  or  the 
quotidian  intermittent  type,  or  occur  in  the  form 
of  isolated  attacks.  The  fever  is  always  of  short 
duration,  and  the  icterus  usually  does  not  appear 
till  the  time  of  defervescence.  The  icterus  has  all 
the  characters  of  a  choluric  icterus,  without 
retention  and  of  mild  course  ;  even  when  there  is 
definite  icterus  the  stools  are  not  colourless,  but 
rather  pleiochromic,  at  least  during  the  first  few 
days.  Examination  of  the  organs  shows  slight 
enlargement  of  the  liver  and  spleen.  Splenomegaly 
here  possesses  great  semeiological  value,  as  it 
presents  the  characters  of  the  splenic  enlargement 
usually  seen  in  the  period  of  acute  paludism,  viz., 
moderate  splenomegaly,  in  which  the  lower  pole 
of  the  organ  reaches  below  the  costal  margin  and 
accompanied  by  a  feeling  of  weight  and  sometimes 
pain  in  the  left  hypochondrium.  This  splenic  en- 
largement suggests  that  this  icterus  is  of  a  malarial 
character,  and  this  suspicion  will  be  confirmed  by 
the  negative  result  of  an  early  blood-culture  for 
typhoid  bacilli  and  by  the  presence  of  hsematozoa 
in  the  blood. ^ 

^  Contrary  to  the  opinion  once  held  it  has  been  established 
nowadays  that  acute  hepatitis  and  abscess  of  the  liver  are  due  to 
the  amoeba  of  dysentery,  and  these  phenomena  may  naturally 
occur  among  malarial  patients. 


978  MALARIA  IN  MACEDONIA 

Syndrome  of  Acute  and  Sub-acute 
Suprarenal  Insufficiency  ^ 

This  syndrome  may  occur  in  persons  whose 
infection  is  only  a  few  weeks  old.  The  manifesta- 
tions have  generally  been  ill-marked,  and  merely 
consist  of  malaise,  headache,  and  a  few  febrile 
attacks,  so  that  the  patients  keep  on  duty,  although 
they  become  very  anaemic. 

Then  all  of  a  sudden  a  violent  attack  takes 
place,  the  temperature  rises  to  104°  F.  or  higher, 
and  then  falls  sometimes  below  normal  to  96*8°. 
The  attack  is  accompanied  from  the  first  by  diges- 
tive disturbances,  repeated  vomiting  and  profuse 
diarrhoea.  The  patient  complains  of  violent  pain 
localized  in  the  lumbar  and  epigastric  regions. 
All  these  symptoms  outlive  the  fall  of  the  tempera- 
ture and  may  persist  till  the  end. 

On  examination  of  the  patient  the  most  striking 
thing  is  his  state  of  anaemia  and  emaciation  ;  his 
look  is  profoundly  altered,  the  features  are  drawn,  the 
nose  pinched,  the  eyes  hollow,  and  the  voice  hoarse. 
The  vomiting  and  diarrhoea  continue,  no  fluid  is 
tolerated,  and  there  is  almost  absolute  anorexia. 
The  lumbar  pains  persist,  and  the  patient  suffers 
from  cramps.  Asthenia  is  the  principal  symptom. 
The  patient  retains  his  lucidity,  but  is  motionless 
and  in  such  a  state  of  prostration  that  he  requires 
an  orderly  to  feed  him,  and  he  is  incapable  of 
sitting  without  support  on  his  bed,  but  falls  back 
almost  lifeless  ;    the  pulse  is  relatively  quickened 

'  G.  Paisseau  and  H.  Lemairc.  L'insuffisance  surreiiale  dans  le 
paludisme.     Presse  medicate ,  Dec.  4,  1916. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  979 

(100-110),  remarkably  small  and  compressible  ; 
the  arterial  hypotension  is  not  only  pronounced, 
but  reaches  the  lowest  possible  level.  The  phe- 
nomenon of  the  white  line  is  present. 

Examination  of  the  viscera  shows  a  normal 
heart  and  liver,  but  a  large  and  tender  spleen, 
which  reaches  two  or  three  fingers'  breadths  below 
the  false  ribs.  The  reflexes  are  feeble  but  present. 
A  fresh  attack  of  fever  may  occur  at  this  moment, 
exceeding  102*2°  F.,  and  in  that  case  the  symptoms 
get  rapidly  worse,  the  asthenia  is  absolute,  the 
slightest  movement  becomes  impossible,  the  tem- 
perature falls  to  96*8°  or  even  95°  F.,  the  pulse 
becomes  barely  perceptible,  and  death  takes  place 
in  a  state  of  progressive  algid  collapse. 

The  total  duration  of  these  symptoms  varies  : 
the  course  may  be  very  rapid,  resembling  an 
attack  of  cholera,  so  that  cases  of  this  kind  have 
been  classified  under  the  name  of  choleriform 
attacks.  The  progress  of  this  syndrome  of  supra- 
renal insufficiency  may  be  more  gradual,  and  only 
be  fatal  in  about  ten  days'  time.  We  have,  in 
fact,  seen  transient  improvement  apparently  due 
to  treatment  by  quinine  and  adrenalin.  The 
influence  of  adrenalin  on  the  vomiting  and 
diarrhoea  appeared  to  us  in  some  cases  to  be  very 
marked ;  the  suprarenal  symptoms,  however, 
reappeared,  and  the  course  of  the  disease  was 
merely  prolonged. 

The  syndrome  of  uncomplicated  suprarenal 
insufficiency  may  pursue  a  less  eventful  course, 
and  the  attack  may  not  be  sufficiently  severe  to 
endanger  life. 


980  MALARIA  IN  MACEDONIA 

Cases  of  this  kind  may  be  classified  in  two  distinct 
categories.  In  the  first  the  syndrome  of  supra- 
renal insufficiency  remains  exclusively  glandular, 
while  in  the  second  it  is  complicated  by  the  pig- 
mentation characteristic  of  Addison's  disease. 

The  first  group  consists  of  recently  infected 
patients,  whose  symptoms  during  the  first  invasion 
did  not  show  any  features  of  abnormal  gravity. 
After  presenting  these  symptoms  they  remain 
anaemic  and  show  slight  digestive  disturbances, 
such  as  nausea,  occasional  vomiting,  and  anorexia, 
but  .their  chief  symptom  is  profound  asthenia. 
They  are  confined  to  bed  in  a  condition  of  pro- 
longed immobility,  and  are  incapable  of  the  slightest 
muscular  effort.  Their  pulse  is  easily  compressible ; 
with  Pachon's  oscillometer  we  found  a  minimum 
tension  of  2°  and  a  maximum  of  9°.  On  question- 
ing them  it  is  found  that  they  frequently  suffer 
from  pains  in  the  lumbar  regions.  Their  general 
condition  did  not  appear  grave ;  when  treated 
methodically  their  symptoms  appeared  to  improve, 
and  the  patients  could  be  evacuated. 

This  syndrome  of  gradual  suprarenal  insufficiency 
may  be  completed  by  the  appearance  of  pigmenta- 
tion. The  pigment  spots  are  situated  in  the  usual 
situation,  viz.,  the  temples,  scrotum,  and  buccal 
mucous  membrane.  The  syndrome  of  Addison's 
disease  is  then  complete. 

Intestinal  and  Peritoneal  Syndromes 

Diarrhoeic  and  dysenteriform  symptoms, — Intes- 
tinal disturbances  are  fairly  frequent  in  malaria. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  981 

They    consist    of   diarrhoea    and    dysentery.     The 
character  of  the  diarrhoea  varies  in  gravity.^ 

As  a  rule  there  is  merely  an  attack  of  bilious 
diarrhoea  associated  with  an  isolated  paroxysm  or 
a  short  series  of  quotidian  attacks.  The  intestinal 
catarrh  begins  and  ends  with  the  fever.  The 
patient  has  about  ten  stools  in  the  twenty-four 
hours.  The  evacuations  are  abundant,  liquid, 
bilious,  mucous,  and  bloody.  Each  stool  is  accom- 
panied by  more  or  less  diffuse  abdominal  pain,  but 
often  most  pronounced  along  the  transverse  and 
descending  colon. 

The  diarrhoeic  syndrome  presents  several  re- 
lapses. A  malarial  patient  who  has  previously  had 
symptoms  of  entero-colitis  during  a  febrile  attack, 
is  subject  to  fresh  outbreaks  on  each  subsequent 
febrile  attack.  It  may  often  happen  that  the  only 
manifestation  of  some  malarial  attacks  is  a 
diarrhoea,  which  serves  as  the  equivalent  of  a 
malarial  attack,  febrile  or  otherwise.  These  out- 
breaks of  malarial  entero-colitis  are  improved  or 
cured  by  quinine.  But  the  intestinal  disturbances 
in  malaria  may  assume  a  more  severe  form,  the 
diarrhoea  being  complicated  by  a  dysenteriform 
syndrome,  especially  in  patients  suffering  from 
more  or  less  severe  continued  fever.  The  diarrhoeic 
syndrome  which  at  first  is  most  in  evidence  is 
shown  by  very  frequent  bilious  discharges  and 
more  or  less  abundant  and  repeated  intestinal 
haemorrhages,  but  tenesmus  and  rectal  gripping 
are  soon  added  to  the  phenomena  of  entero-colitis, 

^  P.  Abrami  and  C.  Foix,  L'enterite  du  pa/udeen.  Reunion 
des  Soc.  Med  de  t A.  0.,  Nov.  7,  1916. 


982  MALARIA  IN  MACEDONIA 

the  stools  become  more  and  more  numerous,  and 
take  on  the  "  frog-spawn  "  appearance  of  dysentery. 
The  dysenteriform  syndrome  has  now  taken  the 
place  of  the  initial  bilious  diarrhoea.  The  patient's 
general  condition  changes,  his  face  becomes  pinched, 
his  voice  becomes  weak,  and  he  dies  in  a  sort  of 
typhoid  state. 

This  dysenteriform  syndrome  sometimes  occurs 
so  early  that  the  patient  appears  to  be  suffering 
from  actual  dysentery  from  the  very  first.  The 
intestinal  manifestations  of  malaria  should  always 
attract  the  doctor's  attention,  as  their  tendency 
to  recur  and  to  become  chronic  predisposes  to  a 
serious  complication,  viz.,  acute  primary  cachexia, 
of  which  we  shall  speak  ater. 

The  diagnosis  of  the  nature  of  these  dysenteri- 
form states  is  often  difficult  owing  to  the  frequent 
co-existence  of  amoebic  or  bacillary  dysentery 
during  the  season  of  a  malarial  epidemic.  Apart 
from  laboratory  information,  the  character  of  the 
fever  accompanying  these  symptoms  will  enable 
the  course  to  be  established  in  the  great  majority 
of  cases. 


Peritoneal  Syndrome 

The  patients  are  sometimes  brought  to  hospital 
with  the  diagnosis  of  appendicitis,  as  in  the  course 
of  a  febrile  attack  they  are  seized  with  vomiting 
and  diffuse  and  violent  lumbo-abdominal  pain. 
The  tenderness  of  the  abdomen  is  so  exquisite  as 
to  suggest  a  peritoneal  reaction,  especially  as  the 
pulse  is  often  very  compressible,  but  the  presence 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  983 

of  diarrhoea,  the  absence  of  precise  localization  of 
the  pain,  and  the  course  of  the  symptoms  which 
rapidly  subside,  negative  the  idea  of  appendicitis, 
which  at  first  seems  absolutely  certain. 

Syndrome  of  Acute  Cachexia 

During  the  period  of  relapses  in  primary  paludism 
we  have  sometimes  observed  a  syndrome  of  con- 
siderable gravity,  viz.,  a  sort  of  cachexia  of  rapid 
course,  ending  fatally  within  a  few  weeks. ^ 

This  syndrome  develops  in  patients  who  have 
generally  had  only  very  slight  symptoms  during 
the  first  invasion.  The  symptoms  merely  consist 
of  a  sense  of  fatigue  or  such  mild  digestive  dis- 
turbances and  transient  febrile  attacks  that  the 
patient  does  not  want  to  be  admitted  to  hospital, 
and  owing  to  the  mild  character  of  the  symptoms 
the  period  of  invasion  esca-pes  notice,  and  the  sub- 
ject does  not  undergo  any  special  treatment. 

During  the  following  weeks  the  patient  appears 
to  become  decidedly  anaemic.  The  anaemia  may 
occur  without  fever  or  on  the  occasion  of  a  febrile 
attack,  which  seems  to  be  the  first  manifestation 
of  the  malarial  infection,  whereas  it  is  already  a 
phenomenon  of  the  period  of  relapses.  The 
syndrome  of  anaemia  pursues  a  progressive  course, 
and  is  almost  always  accompanied  by  fever,  which 
assumes  one  of  the  types  which  we  have  previously 
described,  viz.,  the  continued  form,  the  quotidian 
intermittent,    or  the    tertian    variety.     All    these 

^  G.  Paisseau  and  H.  Lemaire,  La  cachexie  aigue  du  paludisme 
primaire.     Bull.  Soc,  Med.  Hop.  de  Paris,  Dec.  8,  1916. 


984  MALARIA  IN  MACEDONIA 

types  of  fever  may  be  met  with  in  the  same  subject 
succeeding  one  another  without  an  interval  of 
apyrexia. 

Anaemia  is  not  the  only  symptom  which  plays 
a  part  in  this  cachectic  syndrome.  Profound 
asthenia  and  digestive  disturbances,  such  as 
vomiting  and  diarrhoea,  rapidly  supervene.  At 
first  these  symptoms  may  be  only  intermittent, 
not  developing  until  the  outbreak  of  fever,  and 
ceasing  in  the  phase  of  apyrexia.  During  the 
patient's  attacks  of  fever  the  vomiting  and  diarrhoea 
assume  an  almost  uncontrollable  character,  the 
asthenia  is  profound,  the  lumbar  pain  is  very  severe, 
and  the  arterial  tension  is  particularly  low.  It 
may  often  happen  that  these  symptoms,  especially 
the  digestive  disturbances,  last  longer  than  the 
fever,  and  outlive  the  attack  which  seems  to  have 
caused  them.  A  sudden  aggravation  soon  becomes 
obvious  ;  on  the  occasion  of  a  particularly  violent 
febrile  attack  the  vomiting  becomes  more  intense, 
the  stools  more  frequent,  and  the  asthenia  more 
profound  than  they  have  ever  been  before.  The 
anaemia  also  increases,  and  an  icterus  often  appears, 
which,  as  a  rule,  is  transient  and  mild  and  not 
accompanied  by  normal  bile-pigment  in  the 
urine.  Breaking  up  of  the  organism  now  speedily 
takes  place,  and  emaciation  proceeds  very  rapidly. 
The  appearance  of  patients  in  a  state  of  cachexia 
is  particularly  striking,  the  subject  is  profoundly 
anaemic  and  has  an  earthy,  dirty  yellow  complexion, 
his  mucous  membranes  have  lost  their  colour,  and 
the  conjunctivae  are  often  subicteric.  Emaciation 
is  extreme,  especially  in  the  face,  where  the  skin 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  985 

appears  stuck  to  the  bone,  and  the  combination 
of  all  these  changes  gives  the  face  a  remarkable 
appearance  of  precocious  senility.  Asthenia  is  an 
important  symptom  ;  the  patient  is  confined  to 
bed,  as  every  movement  is  a  source  of  fatigue, 
the  arterial  hypotension  is  pronounced,  the  mini- 
mum tension  falling  to  a  very  low  level.  Bed-sores 
develop.  Digestive  disturbances  still  dominate  the 
scene :  vomiting  occurs  whenever  the  patient 
attempts  to  take  food,  the  diarrhoea  is  often 
profuse,  and  both  the  vomiting  and  diarrhoea 
occasionally  assume  a  haemorrhagic  character. 

Further  examination  of  the  patient  shows  slight 
enlargement  of  the  spleen,  which  reaches  or  just 
passes  below  the  level  of  the  false  ribs  ;  the  liver 
is  also  somewhat  enlarged  and  tender  on  pressure, 
but  the  other  viscera  show  nothing  abnormal. 

This  syndrome  of  acute  cachexia  which  we  have 
only  observed  in  malaria  due  to  the  Plasmodium 
falciparum,  has  almost  always  a  fatal  issue. 
But  we  have  seen  a  case  which  threatened  to  be 
fatal  arrested  by  intensive  treatment  with  quinijie 
associated  with  adrenalin.  In  our  opinion  this 
successful  result  can  only  be  obtained  when  the 
digestive  disturbances  and  emaciation  are  not  too 
pronounced. 

Pulmonary  Syndromes 

During  the  period  of  relapses  and  second  attacks 
the  malarial  patient  may  present  pulmonary 
manifestations,  the  clinieal  features  of  which  are 
characteristic  enough  to  justify  their  being  attrib- 
uted to  malaria. 


986  MALARIA  IN  MACEDONIA 

Four  varieties  of  these  syndromes  may  be 
distinguished. 

The  first,  which  is  by  far  the  most  frequent,  is 
a  mild  form  ;  it  is  characterized  either  by  signs 
of  disturbance  of  function  occurring  in  the  course 
of  an  attack  and  consisting  in  a  spasmodic  and 
paroxysmal' cough  with  some  respiratory  distress, 
or  by  signs  of  shght  bronchitis  ;  the  former  dis- 
appear with  tlie  attack,  and  the  latter  persist. 

An  equally  frequent  form  is  bronchitis  with  pleuro- 
pulmonary  congestion.  The  patient  is  re-admitted 
to  hospital  for  pain  in  the  chest,  cough,  dyspnoea, 
and  fever.  On  examination  all  the  signs  of  pleuro- 
pulmonary  congestion  are  found  accompanied  by 
bronchitic  rales.  For  two  or  three  days  one  does 
not  think  of  malaria,  as  there  is  nothing  to  indicate 
it.  But  one  soon  becomes  struck  by  the  changing 
character  of  the  stethoscopic  signs,  which  increase, 
subside,  or  shift  their  position  in  less  than  twenty- 
four  hours  ;  the  patient's  symptoms  and  general 
condition  present  the  same  remissions  and  ex- 
acerbations. These  manifestations  of  pleuro- 
pulmonary  congestion  are  accompanied  by  one 
of  the  types  of  fever  usually  observed  at  this 
period  of  the  disease.  They  are  mild  in  character, 
and  almost  always  end  in  complete  recovery, 
often  in  less  than  a  week.  In  some  cases,  however, 
the  stethoscopic  signs  persist  for  some  days  after 
defervescence,  signs  of  dry  pleurisy  or  even  of  a 
slight  pleural  effusion  being  found. 

The  two  other  forms  which  we  have  observed 
are  much  rarer. 

One  of  them  suggests  a  pneumonia  of  the  apex. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  987 

The  typical  signs  are  present,  such  as  dulness, 
bronchial  breathing  and  crepitant  rales,  but  the 
sputum  generally  remains  viscid  and  only  excep- 
tionally assumes  the  characters  of  that  of  a  frank 
pneumonia.  This  form  of  pneumonia  often 
relapses  in  situ  or  in  another  part  of  the  lung. 
Its  course  runs  parallel  with  that  of  the  fever,  and 
is  definitely  influenced  by  quinine. 

Lastly,  we  may  find  in  malaria  the  typical 
picture  of  pulmonary  apoplexy  which  often  has  a 
rapidly  fatal  termination ;  but  this  complication  is, 
fortunately,  very  exceptional. 


Cahdio- Vascular  Syndromes 

The  circulatory  system  does  not  always  escape 
in  the  course  of  primary  paludism.  We  have 
chiefly  observed  disturbance  of  the  peripheral 
circulation  and  in  the  extremities  of  the  limbs. 
These  circulatory  disorders  present  all  degrees  of 
severity,  ranging  from  Raynaud's  disease  to 
symmetrical  gangrene  of  a  considerable  segment 
of  a  limb.  Raynaud's  disease  in  its  attenuated 
form  may  take  on  the  cyclical  course  of  a  malarial 
paroxysm  with  exacerbations  and  remissions 
parallel  with  those  of  the  fever.  In  the  severest 
cases  it  may  be  permanent  and  be  associated 
with  small  areas  of  sloughing.  Patients  suffering 
from  this  complication,  who  have  contracted  a 
severe  infection,  find  that  their  lesions  are  im- 
proved and  cured  by  quinine. 

Symmetrical  gangrene  of  the  limbs  which  usually 
involves  the  feet  and  the  lower  third  of  the  legs, 


988  MALARIA  IN  MACEDONIA 

has  a  more  rapid  and  acute  course.  We  have 
seen  it  occur  in  febrile  attacks  of  malaria,  and 
frequently  in  the  course  of  pernicious  attacks. ^ 
The  patient  generally  dies  of  malaria,  but  we  have 
seen  a  case  which  recovered  through  the  combined 
action  of  quinine  and  adrenalin  in  intravenous 
injections.  For  the  sake  of  completeness  we  may 
mention  that  some  cases  of  erythromelalgia  have 
been  attributed  to  malaria.  The  peripheral  cir- 
culation is  not  the  only  one  affected.  The  visceral 
arteries  present  lesions  of  endarteritis  like  those 
of  the  peripheral  arteries,  which  accounts  for  the 
unexpected  occurrence  of  visceral  syndromes  in 
acute  paludism.  Among  the  latter,  especially 
affecting  the  circulatory  system,  we  should  like 
to  draw  attention  to  the  occasionally  fatal  attacks 
of  angina  pectoris  with  changes  in  the  coronary 
arteries. 

Urinary  Syndromes 

Urinary  syndromes  are  exceptional  in  primary 
paludism.  The  only  examples  of  this  kind  which 
we  have  seen  have  been  a  few  cases  of  albuminuria 
occurring  at  the  time  of  the  febrile  paroxysms. 
The  albuminuria  was  always  slight  and  transient. 
As  a  rule  the  patient  was  suffering  from  decided 
anaemia,  and  had  been  admitted  to  hospital  for 
this  complication  of  malaria.  In  the  patient's 
past  history  we  have  more  than  once  met  with 

*  Alamartine,  Soc.  des  Sciences  Med.  A.  0.,  1916.  Paisseau 
and  Lemaire,  Deux  cas  de  gangrene  palustre.  Bull.  Soc.  Med. 
Hop. ,  Feb.  9,  1917.  Laurent  Moreau,  Presie  m^dicnle,  March 
22,  1917. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  989 

an   illness   like   severe   scarlet   fever   which   might 
account  for  a  previous  renal  affection. 

In  three  cases,  however,  we  observed  a  real 
acute  nephritis  in  every  way  resembling  that  of 
secondary  syphilis  including  massive  albuminuria 
to  the  amount  of  15-30  grammes  in  the  twenty- 
four  hours,  and  a  considerable  degree  of  oedema. 
In  two  cases  quinine  caused  the  phenomena  to 
subside  rapidly.  In  the  third  case,  on  the  contrary, 
it  aggravated  them. 

Early  bilious  haemoglobinuric  fever. — At  the 
height  of  the  malarial  epidemic  in  August  and 
September  we  saw  some  cases  of  haemoglobinuric 
fever  in  patients  who  were  in  the  period  of  relapses 
of  primary  paludism,  but  these  cases  were  ex- 
ceptional. Most  of  the  cases  of  bilious  haemo- 
globinuric fever  occurred  in  the  cold  season  at 
a  later  stage  of  primary  paludism,  or  more  fre- 
quently, in  the  course  of  secondary  paludism. 
We  will,  therefore,  reserve  the  description  of  this 
complication  for  the  last  period  of  the  disease, 
where  will  also  be  found  an  account  of  the  chnical 
features  of  bilious  haemoglobinuric  fever  of  the 
period  of  relapses,  the  prognosis  of  which  is  always 
very  gloomy. 

Nervous  Manifestations 

The  changes  in  the  nervous  system  have  been 
specially  studied  in  the  hospitals  at  Salonica  by 
our  friend  and  colleague  Dr  Monier-Vinard,  to 
whom  we  are  indebted  for  the  following  in- 
formation. 


990  MALARIA  IN  MACEDONIA 

Nervous  symptoms,  apart  from  those  corre- 
sponding to  the  meningeal  reaction  observed  in 
the  forms  which  are  severe  from  the  onset, ^ 
as  a  rule  do  not  occur  until  several  months  after 
infection,  and  often  only  in  the  course  of  secondary 
paludism ;  and  it  is,  therefore,  in  autumn  and 
winter  that  they  are  most  frequently  observed. 
They  may  be  divided  into  neuralgia,  neuro- muscular 
disorders,  and  polyneuritis.  Occasionally  focal 
lesions  of  the  nerve  centres  may  be  observed. 

Neuralgia. — This  most  frequently  affects  the 
ophthalmic  branch  of  the  trigeminal  nerve,  and 
is  often  accompanied  by  trophic  lesions  of  the  eye 
and  its  appendages,  as  we  shall  see  later,  as  well 
as  by  palpebral  and  labial  herpes  zoster.  Sciatica 
is  also  a  favourite  localization. 

All  the  varieties  of  malarial  neuralgia  have 
features  in  common  ;  they  are  generally  unilateral, 
present  periodic  paroxysms,  especially  in  the 
night  or  morning,  and  are  unaffected  by  most 
analgesic  remedies,  while  they  are,  on  the  contrary, 
remarkably  influenced  by  quinine. 

Neuro  -  muscular  disturbances.  —  These  are 
chiefly  seen  in  patients  who  have  been  subject  to 
fatigue  and  belong  to  the  group  of  cases  for  which 
Babinski  has  suggested  the  name  of  physiopathic 
disturbances.  The  symptoms  are  chiefly  motor, 
sometimes  both  sensory  and  motor,  being 
characterized  by  muscular  cramps,  usually  situated 
in  the  calf  but  occasionally  affecting  a  large  number 

^  Monier-Vinard,  Paisseau,  and  Lemaire,  Cytologie  du  liquide 
cephalo-Bachidien  au  cours  de  faeces  palustre.  Bull,  Soc.  Med. 
Hop.,  Oct.  20,  iyi6. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  991 

of  muscles.  The  cramps  often  co-exist  with  febrile 
attacks. 

Muscular  hypertonus  may  also  be  observed, 
being  revealed  objectively  and  subjectively  by 
muscular  rigidity  frequently  existing  with  muscular 
asthenia. 

Exaggeration  of  the  tendon  reflexes  is  the  rule, 
idio-muscular  excitability  on  percussion  is  increased 
in  the  affected  muscles,  and  electrical  examination 
shoWs,  according  to  the  case,  the  myasthenic  re- 
action, the  myotonic  reaction,  and  more  rarely  the 
galvanotonic  reaction. 

The  motor  phenomena  are  sometimes  associated 
with  anaesthesia  to  pricking  and  even  to  burning, 
with  a  segmental  or  radicular  topography. 
Cyanosis  with  slight  swelling  of  the  extremities 
is  also  very  frequently  met  with,  and  the  patients 
then  complain  of  a  sensation  of  cold  and  numbness. 
Pollakiuria  is  often  present,  being  due  to  changes 
in  the  excitability  of  the  cord. 

The  natural  course  of  these  symptoms  is  to 
end  in  recovery,  though  this  may  require  weeks, 
and^often  even  months. 

Polyneuritis. — This  seems  to  be  rarer  than 
some  authors  have  stated.  Other  toxic  and 
infective  processes  which  may  be  associated  with 
the  malarial  infection  must  be  taken  into  account. 
During  the  cachectic  stage  of  the  disease,  however, 
diffuse  polyneuritis  may  be  observed,  manifested 
in  the  limbs  by  diminution  of  the  reflexes,  wander- 
ing pains  and  even  muscular  atrophy. 

Focal  lesions. — These  are  due  to  the  same 
process   as    the   meningeal    haemorrhages    and   are 


992  MALARIA  IN  MACEDONIA 

almost  always  the  result  of  a  congestive  attack. 
They  are  relatively  rare.  They  may  present  the 
characters  of  a  simple  hemiparesis  or  a  paralysis 
of  the  Weber  or  Millard-Gubler  type.  Right 
hemiplegia  with  motor  aphasia  has  sometimes 
been  observed. 

Mental  disorders. — These  have  been  specially 
studied  in  the  army  of  the  East  by  our  friend  Dr 
Vinchon,  who  has  supplied  us  with  the  following 
information. 

Malaria,  like  all  other  infections,  may  be  associ- 
ated with  mental  disorders,  the  origin  of  which 
may  be  explained  by  the  patient's  antecedents, 
whether  hereditary  (degeneration)  or  acquired 
(alcoholism).  These  disorders,  which  occur  in  all 
stages  of  the  disease,  appear  in  several  forms, 
such  as  delirious  or  convulsive  attacks  and  asthenia. 
Moreover,  the  course  of  pre-existing  psychoses  is 
accelerated  or  aggravated. 

The  attacks  of  delirium  are  of  varying  duration 
and  consist  of  two  types  :  1.  Mental  confusion 
with  oneiric  delirium.  2.  Melancholia  with  anxiety 
without  confusion. 

The  first  form  is  the  more  serious  of  the  two  ; 
physical  signs,  such  as  a  tendency  to  cardiac 
collapse  and  dyspnoea,  are  a  bad  prognostic.  In 
the  second  form,  which  is  milder,  the  delirium  may 
or  may  not  disappear  with  the  fall  of  the  tempera- 
ture ;  if  it  persists,  as  well  as  the  physical  disturb- 
ances, a  relapse  is  to  be  feared,  in  which  death 
often  occurs  with  hyperpyrexia  or  with  a  subnormal 
temperature,  after  a  fresh  attack. 

Convulsions,  which  are  chiefly  due  to  congenital 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  993 

predisposition  are  attacks  resembling  those  of 
hysteria,  and  sometimes  begin  with  severe  pain 
in  the  splenic  region.  Malarial  asthenia,  whether 
it  occurs  early  or  late,  is  aggravated  and  prolonged 
by  anaemia,  but  in  some  cases  it  may  persist  after 
the  latter  has  disappeared.  Malaria  causes  a 
return  of  attacks  of  periodic  psychosis,  a  more 
rapid  evolution  of  dementia,  and  an  aggravation 
of  hypochondriacal  or  persecutional  delirium,  based 
on  hallucinations  or  delirious  interpretations.  The 
treatment  is  that  of  malaria  associated  with  that 
suitable  for  mental  disorders.  Heliotherapy,  as 
well  as  hydrotherapy,  yields  excellent  results. 
Lastly,  in  the  course  of  attacks  of  delirium  or 
asthenia,  malaria  gives  rise  to  medico-legal  compli- 
cations, especially  fugues  and  attempted  suicide. 

Ocular  Complications. 

These  have  been  studied  in  a  very  large  number 
of  cases  by  our  colleague  and  friend,  Dr  Chavernac, 
who  is  in  charge  of  the  ophthalmological  depart- 
ment, and  we  are  indebted  to  him  for  the  following 
information.  The  complications  may  affect  the 
nerves  of  the  eye  and  its  vascular  system. 

Symptoms  of  affection  of  the  sensory  nerves. — 
KeratitU  is  frequently  observed,  being  closely 
associated  with  neuralgia  of  the  trigeminal,  and 
generally  occurs  from  two  to  three  days  after  the 
paroxysm  which  was  the  cause  of  it.  It  is  usually 
accompanied  by  palpebral  herpes  and  is  almost 
always  complicated  by  iritis  with  slight  hypotonus 
of  the  eyeball. 


994  MALARIA  IN  MACEDONIA 

It  is  superficial  and  slight  in  the  case  of  infection 
by  the  plasmodium  vivax,  but  obstinate  and 
difficult  to  cure  in  the  case  of  plasmodium  falci- 
parum infection.  It  may  assume  any  of  the 
following  types  :  phlyctenular,  vesicular,  dendritic, 
annular,  disciform,  nodular,  striated  or  ulcerative 
marantic. 

To  effect  a  cure  it  is  necessary  to  adopt  an  in- 
tensive quinine  treatment  as  well  as  local  treatment 
with  atropine.  Secretory  disorders  may  be  observed 
in  the  form  of  lacrymation  lasting  several  hours 
during  the  neuralgic  paroxysm. 

Symptoms  of  affection  of  the  motor  nerve. — 
These  consist  cither  in  affection  of  the  extrinsic 
muscles,  such  as  paresis  or  permanent  paralysis, 
involving  especially  the  superior  rectus,  the  ex- 
ternal rectus,  or  the  muscles  of  convergence,  or 
in  affection  of  the  intrinsic  muscles,  causing 
paresis  or  cramps  of  accommodation. 

Symptoms  of  affection  of  the  optic  nerve. — 
These  consist  of  subjective  phenomena,  such  as 
transient  or  permanent  amblyopia,  coloured  vision 
(erythropsia,  cyanopsia,  xanthopsia),  hemeralopia 
and  hemianopsia.  Hemianopsia  was  found  to  be 
excessively  frequent,  several  hundreds  of  cases 
having  been  observed,  almost  exclusively  in  the 
hot  season. 

Quinine  amaurosis,  on  the  contrary,  was 
exceptional,  in  spite  of  the  considerable  number 
of  cases  under  treatment.  Only  one  case  was 
seen  by  Dr  Chavernac,  so  that  the  apprehension 
of  this  complication  should  never  be  a  contra- 
indication to  the  use  of  large  doses  of  quinine. 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  995 

Changes  in  the  vascular  system. — Conjunctival 
hcemorrhages  are  frequent,  but  have  no  effect 
on  vision. 

Iritis  is  a  frequent  complication  of  keratitis,  but 
rarely  exists  as  an  isolated  phenomenon.  It  is 
influenced  by  the  febrile  attacks,  which  may 
provoke,  aggravate,  or  prolong  it,  but  it  subsides 
without  leaving  any  trace. 

Uveitis  of  protracted  course  was  observed  in  two 
cases. 

Chorio-retinitis  is  very  frequent  in  individuals 
who  have  been  infected  several  months  previously, 
and  appears  in  the  form  of  peri-papillary  deposits 
of  pigment,  the  abundance  of  which  may  cause  a 
diminution  of  vision.  Quinine  has  no  action  upon 
them. 

Congestion  of  the  retina  is  a  common  occurrence 
in  the  course  of  an  attack,  the  veins  are  swollen 
and  the  macula  is  dark  red. 

Exudations  appear  in  the  form  of  slight  greyish 
films  masking  in  places  the  outline  of  the  vessels  ; 
they"  may  even  run  together  and  form  an  agglo- 
meration with  circular  outline. 

Retinal  hcemorrhages  are  macular  or  peri-papil- 
lary, and  pre-retinal,  intra-retinal,  or  retro-retinal. 
They  usually  become  absorbed  fairly  quickly, 
but  they  may  give  rise  to  atrophy  of  the  retina. 
They  are  easily  seen  with  the  ophthalmoscope,  and 
are  always  situated  in  the  area  supplied  by  the 
short  posterior  ciliary  arteries. 

Laryngeal  and  aural  complications. — The 
laryngeal  complications  of  malaria  which  have 
been  studied  by  our  friend  Dr  de  la  Mothe  are 


^QQ  MALARIA  IN  MACEDONIA 

almost  exclusively  of  a  motor  character.  We  have, 
in  fact,  never  come  across  a  case  of  laryngeal  in- 
flammation which  could  be  undoubtedly  attributed 
to  malaria. 

Aphonia  may  develop  more  or  less  suddenly, 
usually  after  severe  attacks  and  almost  always 
in  association  with  marked  asthenia.  The  voice 
is  faint,  whispering  and  toneless,  being  interrupted 
owing  to  the  waste  of  the  air  column,  the  glottis 
closing  incompletely. 

This  aphonia  may  be  due  to  two  causes. 
1.  More  or  less  pronounced  paresis  of  the  con- 
strictors of  the  glottis  and  tensors  of  the  vocal 
cords. 

2.  A  true  recurrent  paralysis  of  one  vocal  cord, 
which  is  less  frequently  met  with  and  may  or  may 
not  end  in  recovery.  The  prognosis  is  favourable. 
As  regards  treatment,  one  should  wait  until  the 
state  of  asthenia  has  disappeared.  A  few  courses 
of  faradization  and  re-education  will  €hen  be 
enough  to  restore  the  patient's  voice. 

Two  other  exceptional  conditions  have  been 
observed  : 

1.  A  case  of  paralysis  of  the  dilators  of  the 
larynx,  the  right  vocal  cord  being  immobilized 
in  the  median  position.  This  phenomenon  being 
unilateral  was  not  accompanied  by  any  disturb- 
ance of  function.  It  is  reasonable  to  suppose 
that  in  some  cases  this  paralysis  may  be  double, 
the  glottis  being  entirely  closed,  in  which  case 
intense  respiratory  distress  will  develop  and 
necessitate  tracheotomy. 

2.  Several     cases     of     motor     inco-ordination, 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  997 

difficult  to  interpret,  in  which  the  laryngeal  dis- 
orders are  associated  with  disturbance  of  speech 
resulting  from  the  affection  of  other  centres. 

Auditory  disturbances. — In  our  opinion  there 
is  not  such  a  thing  as  quinine  deafness.  All  the 
patients  admitted  to  hospital  with  this  diagnosis 
whom  we  have  seen  up  till  now  were  suffering  from 
old  lesions  of  the  middle  ear.  Quinine  causes  a 
temporary  congestion  and  gives  rise  to  tinnitus, 
but  these  auditory  disturbances  are  transient 
and  disappear  rapidly  without  leaving  any  trace. 

We  have  had  no  opportunity  of  seeing  a  case  of 
deafness  from  affection  of  the  labyrinth  or  the 
cochlear  nerve  due  to  malarial  mfection.  On 
the  other  hand,  we  have  observed  two  cases  of 
disturbance  of  equilibrium  with  loss  of  excitability 
of  the  vestibular  nerve.     Both  cases  improved. 

3.  Pernicious  Attacks 

Throughout  the  period  of  primary  paludism, 
often  even  within  the  first  weeks  following  the 
invasion,  the  malarial  patient  may  present  symp- 
toms of  such  special  gravity  and  with  such  a  violent 
and  dramatic  course  that  they  have  been  entitled 
j)ernicious  attacks. 

This  pernicious  character,  to  which  some  writers 
have  tried  to  attach  a  mysterious  significance,  is 
simply  due  to  the  association  of  two  factors  : 
invasion  by  a  large  number  of  parasites  and 
dimmution  of  the  resistance  of  the  organism. 
In  all  cases  under  our  observation  examination  of 
the  blood  during  life  and  before  quinine  treatment, 


998 


MALARIA  IN  MACEDONIA 


frequently  showed  an  enormous  proportion  of  the 
red  corpuscles  affected  by  the  parasite  ;  on  autopsy 
the  visceral  capillaries  were  crowded  with  haema- 
tozoa  always  belonging  to  the  variety  of  Plasmodium 

falciparum.  Further- 
more, persons  suffering 
from  pernicious  attacks 
are  generally  men  who 
have  been  subjected  to 
overwork  and  fatigue. 
This  intense  parasitic 
invasion,  associated 
with  these  causes  of 
breaking  down  of  the 
organic  resistance, 
offers  an  explanation  of 
the  profound  lesions 
always  observed  in 
some  viscera  such  as 
the  nerve  centres  and 
the  suprarenal  cap- 
sules. 

The  pernicious  at- 
tack generally  occurs 
in  an  individual  who 
appears  to  be  in  perfect 


<'.a»fr»-»>-^« 


Fig. 


12. — Pernicious  attack,  of  the 
a[)oplectic  type. 


health  and  is  suddenly  taken  ill  while  engaged  in 
his  ordinary  duties.  But  it  may  also  develop  in  a 
patient  already  under  treatment  for  some  malarial 
manifestation.  A  rapid  and  unexpected  aggrava- 
tion ensues,  which  may  cause  death  in  less  than 
forty-eight  hours. 

It  is  usual  to  describe  a  large  number  of  types 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  999 

of  pernicious  attacks,  e.g.,  the  cerebral,  algid,  de- 
lirious, bilious,  diaphoretic,  choleriform,  gastralgic, 
cardialgic,  dyspnoeic,  etc. 

We  will  describe  only  two  sorts  of  pernicious 
attacks,  viz.,  the  cerebral  attack  and  the  algid 
attack,  for  the  cases  which  we  have  observed,  and 
which  might  be  regarded  as  other  forms  of  per- 
nicious attacks,  did  not  seem  to  us  to  present  a 
sufficiently  violent  and  rapid  course  to  justify 
their  classification  among  these  forms  of  malaria. 

Cerebral  forms. — The  cerebral  attack  presents 
two  clinical  types  :  the  apoplectic  attack  and  the 
convulsive  attack. 

Apoplectic  attack,  insolation  type. — The  patient 
is  suddenly  seized  in  the  middle  of  his  work 
with  symptoms  resembling  those  of  heat  stroke. 
He  has  merely  been  complaining  of  fatigue, 
headache,  and  insomnia  for  a  few  days,  when 
all  of  a  sudden  he  becomes  giddy  and  falls 
down  in  the  road  in  a  state  of  apoplexy.  His 
face  is  bloated  and  his  respiration  sighing.  He 
presents  conjugate  deviation  of  the  eyes  and 
complete  muscular  relaxation.  The  last  symptom, 
however,  is  often  succeeded  by  slight  hypertonus, 
especially  in  the  upper  limb,  as  indicated  by  flexion 
contracture  of  the  forearm  :  the  deviation  of  the 
head  and  eyes  is  not  always  conjugate,  but  is  often 
opposed.  These  two  symptoms  indicate  a  cortical 
localization  with  a  meningeal  reaction,  which  is 
confirmed  by  the  existence  of  a  cerebro-spinal 
lymphocytosis. 

The  patient's  temperature  rises  at  once  103*2° 
or  104°,  or  even  105*8°  F.     Death  may  occur  in  a 


1000  MALARIA  IN  MACEDONIA 

few  hours.  In  other  cases  some  improvement 
may  take  place  in  twelve  to  eighteen  horns'  time. 
The  patient  gradually  wakes  up  out  of  his  torpor, 
asks  some  questions  and  calls  for  a  drink.  If 
examination  of  the  blood  has  been  made  and  any 
kind  of  injection  of  quinine  has  been  given,  especi- 
ally an  intravenous  one,  improvement  takes  place 
very  rapidly,  the  temperature  falls  progressively 
ill  two  or  three  days,  or  on  the  other  hand  the 
patient  remains  febrile  and  presents  a  sub-con- 
tinuous fever,  which  is  usually  very  little  affected 
by  quinine.  This  apoplectic  attack  is  sometimes 
accompanied  by  signs  of  focal  lesions,  e.g.,  hemi- 
plegia or  aphasia. 

Hemiplegic  variety. — In  some  cases  a  unilateral 
predominance  of  the  symptoms  of  paresis  may  be 
found  at  the  time  of  the  loss  of  consciousness, 
constituting  an  actual  hemiplegia  or  hemiparesis. 
The  course  is  the  same  as  in  the  previous  case. 
The  paretic  phenomena  disappear  entirely  under 
the  influence  of  quinine,  and  the  patient  recovers 
consciousness  simultaneously. 

Aphasic  variety. — Before  the  comatose  period 
or  when  it  is  passing  away,  some  patients  may 
show,  either  with  or  without  a  right-sided  paresis, 
symptoms  of  motor  aphasia,  which  may  last  some 
hours,  but  also  yield  to  treatment. 

Convulsive  meningeal  form. — The  pernicious 
attack  starts  with  convulsive  phenomena  of  the 
epileptiform  type,  which  may  simulate  a  true 
attack  of  epilepsy  ;  there  is  also  contracture  of 
the  limbs,  nuchal  rigidity,  and  sometimes  con- 
jugate  or  dissociated   deviation  of  the  head   and 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  1001 

eyes,  accompanied  by  persistent  coma  with  a  rise 
of  temperature  to  104°  or  105*8°  F.  Examination 
of  the  blood  and  discovery  of  the  causal  agent 
lead  to  the  adoption  of  quinine  treatment.  We 
may  add  that  in  these  cases  the  cerebro-spinal 
fluid  shows  considerable  lymphocytosis,  definite 
albumin,  and  slight  hypertension. 

In  some  cases  transient  coma  is  met  with, 
accompanied  by  icterus,  vomiting,  and  bilious 
diarrhoea.  These  phenomena  correspond  to  the 
bilious  attack  described  in  textbooks. 

Algid  form.^  —  In  this  well-known  form  of 
pernicious  attack  the  patient's  appearance  is 
characteristic  ;  the  initial  symptoms  are  often  the 
same  as  in  an  ordinary  attack,  but  the  fever  is 
particularly  high.  It  is  accompanied  by  nervous 
disorders,  which  are  sometimes  intense,  delirium, 
and  almost  uncontrollable  vomiting. 

But  the  picture  suddenly  changes  completely, 
the  temperature  drops,  falling  to  96*8°  and  lower, 
and  the  various  symptoms  of  algid  collapse  set  in. 

The  patient  then  presents  a  characteristic 
appearance.  He  remains  quite  still,  in  a  condition 
of  profound  asthenia,  the  face  is  drawn,  the  eyes 
sunken,  fixed  and  expressionless  ;  the  nose  pinched 
and  the  voice  hoarse.  The  face  is  often  discoloured 
by  violet  patches,  the  extremities  of  the  hands 
and  feet  are  cyanosed  and  cold  as  ice,  the  skin 
covered  with  clammy  sweat,  and  the  respiration 
is  shallow.     The  pulse  is  only  slightly  accelerated, 

*  Paisseau  and  Lemaire^  Acces  pemicieux  palustres  et  sur- 
renalite  ai^USe.  Bull.  Acad.  Med,,  Oct.  17,  1916,  and  Bull.  Soc. 
Med.  Hop.,  Oct.  13,  1916. 


1002  MALARIA  IN  MACEDONIA 

and  is  small  and  compressible,  and  the  arterial 
pressure  is  very  low ;  we  have  noted  the  phe- 
nomenon of  the  white  line.  The  heart  sounds 
keep  their  normal  rhythm,  but  are  simply 
weakened. 

This  syndrome  of  algidity  and  hypotension  is 
very  often  associated  with  a  series  of  secondary 
symptoms  chiefly  affecting  the  alimentary  canal. 
There  is  repeated  vomiting,  accompanied  by 
profuse  diarrhoea  and  lumbar,  abdominal  and 
epigastric  pain,  and  the  patient  often  complains  of 
painful  cramps.  The  picture  of  a  choleriform 
attack  is  thus  complete.  Death  may  occur 
suddenly,  consciousness  being  retained  till  the 
end.  When  the  attack  ends  in  recovery,  which  is 
exceptional,  the  arterial  tension  rises  as  well  as  the 
temperature,  the  extrenlities  l)ecome  warm  again, 
and  abundant  perspiration  develops,  marking  the 
end  of  the  attack.  The  algid  attack  is  of  the 
utmost  gravity,  but  there  is,  nevertheless,  some 
hope  of  saving  the  patient  by  the  combined  action 
of  quinine  and  adrenalin  in  intravenous  injections. 

4.  Defaced  Paludism  and  Masked  Paludism 

Defaced  paludism. — Defaced  paludism  may  be 
regarded  as  an  attenuated  form  of  malarial  in- 
fection. It  is  found  in  persons  who  have  been 
only  very  slightly  exposed  to  infection,  or  in  those 
living  in  easy  circumstances  and  possessing  a 
sort  of  natural  immunity.  It  is  a  kind  of  almost 
apyretic  paludism,  in  which  the  visceral  localiza- 
tions are  few  and  slight.     The  initial   manifesta- 


SECOND  ATTACKS  IN  PRIMARY  PALUDISM  1003 

tions  consist  of  an  ill-marked  febrile  malaise. 
They  may  be  so  trivial  that  they  pass  unnoticed 
by  patients  who  do  not  pay  niuch  attention  to 
their  ailments. 

Subsequently,  instead  of  the  febrile  attacks  of 
the  period  of  relapses  and  second  attacks,  the 
patients  have  incomplete  attacks  only.  Fever, 
though  often  denied,  is  not  completely  absent, 
but  is  slight  and  curtailed  ;  it  has,  as  a  rule,  com- 
pletely disappeared  when  the  other  symptoms 
attract  the  patient's  attention.  These  symptoms 
are  mostly  of  a  subjective  character,  such  as 
neuralgia,  headache,  lassitude,  and  asthenia,  which 
are  succeeded  by  a  sense  of  well-being.  Close 
examination  suggests  a  certain  degree  of  anaemia, 
which  is  confirmed  by  haematological  examination, 
and  can  often  be  found  in  this  way  even  in  persons 
of  florid  appearance.  This  anaemia  has  the  haema- 
tological appearances  of  the  malarial  anaemia 
which  we  described  above.  It  consequently  pos- 
sesses a  real  semeiological  value.  Its  presence,  if 
it  does  not  actually  warrant  a  certain  diagnosis  of 
malaria,  at  all  events  suggests  it,  even  in  the 
absence  of  the  haematozoon,  which  is  often  not 
present  in  this  form. 

Masked  paludism. — In  masked  paludism  visceral 
manifestations  take  the  place  of  febrile  phenomena, 
which  are  almost  entirely  absent. 

It  is  a  form  of  paludism  which  runs  its  course 
without  fever.  During  the  period  of  invasion  the 
symptoms  are  reduced  to  a  minimum  ;  the  patient 
only  complains  of  headache,  vague  digestive  dis- 
turbances,  with   nausea,   anorexia,   fatigue,   slight 


1004  MALARIA  IN  MACEDONIA 

asthenia,  and  some  lumbar  pain,  all  of  which  he 
attributes  to  the  heat  and  overwork. 

He  has  already  forgotten  these  symptoms  when 
several  weeks  and  even  several  months  later  he 
presents  various  non-febrile  disorders,  which  do 
not  in  any  way  suggest  malarial  manifestations, 
such  as  disturbances  of  the  nervous  system,  organs 
of  special  sense  and  viscera. 

Anaemia  is  certainly  the  most  usual  manifes- 
tation of  masked  paludism.  As  its  malarial  origin 
is  easily  overlooked  in  the  absence  of  characteristic 
febrile  phenomena,  it  gradually  assumes  its  most 
pronounced  features,  giving  rise  to  the  severest 
clinical  and  hsematological  forms.  This  anaemia 
of  masked  paludism  assumes  the  type  of  haemor- 
rhagic  anaemia  or  pernicious  anaemia  which  we 
have  described.  It  is  often  the  prodromal  stage 
of  acute  cachexia.  Masked  paludism  may  also 
consist  of  nervous  phenomena  only,  especially  of 
a  peripheral  character,  or  neuralgias  of  the  type 
which  we  have  described  above,  and  manifestations 
of  the  organs  of  special  sense,  particularly  the  eye. 


Chapter  V 

SECONDARY  PALUDISM 

Secondary  paludism  is  chaFacterized  by  the 
appearance  of  disciplined  febrile  attacks,  which  are 
also  called  frank  attacks  (ague  fits). 

We  adopt  the  term  "  disciplined,"  because  it 
exactly  expresses  the  regularity  of  the  temperature 
curve  of  the  attack,  which  is  closely  connected 
with  the  biological  evolution  of  the  parasite  within 
the  organism.  This  evolution  is  one  of  the  best 
established  conceptions  of  the  parasitological  study 
of  the  haematozoon.  This  is  the  schizogonic  or 
parthenogenetic  evolution,  the  cycle  of  which  is 
completed  in  forty-eight  hours.  It  is  the  asexual 
cycle  which  we  described  above  in  the  chapter 
on  parasitology. 

The  regular  succession  of  these  evolutional 
cycles  gives  rise  to  typical  tertian  intermittent 
fever;  but  under  the  action  of  various  causes 
(increase  in  resistance  of  the  organism,  or  quinine 
treatment)  it  may  be  interrupted. 

It  can  readily  be  understood  that  secondary 
paludism  can  only  assume  this  disciplined  char- 
acter if  the  patient  is  not  exposed  to  fresh  in- 
oculations. 

It  is  therefore  the  kind  of  paludism  met  with 
in  persons  who  have  returned  to  a  non-malarial 

1005 


1006  MALARIA  IN  MACEDONIA 

district,  or  one  which  in  the  case  of  infected 
countries  only  appears  in  the  cold  season  after 
disappearance  of  the  mosquitoes  which  propagate 
the  virus. 

It  should  not  be  forgotten,  however,  that  some 
persons  make  their  first  acquaintance  with  malaria 
in  its  secondary  period.  Such  is  the  typical 
history  of  the  colonial  who  has  his  first  attack 
on  returning  home,  as  frequently  occurred  among 
the  soldiers  in  the  army  of  the  East.  As  a  rule, 
the  patients  are  those  in  whom  the  symptoms 
of  the  first  invasion  were  very  slight  and  passed 
unnoticed ;  sometimes,  however,  the  patient  on 
being  questioned  has  no  recollection  of  any  malaise, 
and  it  is  possible  that  the  primary  period  really 
has  no  symptoms. 

The  ague  fit  being  the  essential  element  in  the 
febrile  curve  of  secondary  paludism,  we  shall 
describe  it  first  of  all.  We  shall  then  show  how 
these  attacks  may  recur,  and  take  place  at  longer 
or  shorter  intervals,  thus  giving  rise  to  a  variety 
of  temperature  curves. 

Previous  visceral  lesions  may  leave  sequel.T, 
which  will  appear  again  in  this  secondary  period 
of  paludism,  and  will  be  revealed  by  symptoms 
which  are  usually  attenuated. 

The  ague  fit. — A  man  who  appeared  to  be  in 
good  health  or  only  slightly  anaemic,  is  suddenly 
seized,  usually  late  in  the  forenoon,  with  violent 
shivering  and  malaise  so  that  he  is  compelled  to 
lie  down.  His  teeth  chatter,  and  he  shakes  from 
head  to  foot.  His  face  is  pale,  his  look  anxious, 
and  his  eyes  bright.     The  pulse  is  quick,  and  the 


SECONDARY  PALVDISM  1007 

extremities  cold.  The  temperature  meanwhile 
has  risen  to  100*8°.  But  in  about  half  an  hour's 
time  the  patient,  who  had  rolled  himself  up  in 
his  blankets  to  get  warm,  begins  to  feel  a  sensation 
of  intolerable  heat.  At  the  same  time  an  intense 
headache  sets  in,  often  accompanied  by  pain  in  the 
back  ;  the  skin  is  dry  and  burning.  The  cheeks 
are  flushed,  the  patient  complains  of  dryness  of  the 
throat  and  intense  thirst  which  even  iced  Avater 
cannot  quench.  The  temperature  rises  rapidly 
to  104°  or  above. 

There  is  an  acute  feeling  of  discomfort,  which  is 
often  accompanied  by  nausea  and  even  vomiting. 

This  condition  persists  for  two  or  three  hours, 
and  then  an  abundant  and  profuse  perspiration 
breaks  out. 

The  patient  then  experiences  a  sensation  of 
well-being.  He  covers  himself  again  to  avoid  the 
chilling  caused  by  the  sweating,  w^hich  stops  in 
an  hour's  time.  The  fever  has  then  fallen  below 
100*8°,  but  the.  normal  temperature  is  only  reached 
about  10  p.m.,  about  twelve  hours  after  the  onset 
of  the  shivering. 

The  patient  now  falls  asleep,  passes  a  good  night, 
and  the  next  day  thinks  that  he  is  cured,  although 
he  feels  a  little  languid.  The  temperature  is 
normal,  and  he  resumes  his  occupation  until  the 
onset  of  the  next  fit,  which  will  be  identical  with 
the  preceding. 

A  close  study  of  the  temperature  taken  every 
half  hour,  shows,  as  we  have  said,  that  at  the 
beginning  of  the  fit  it  is  already  100*8°  F.  Then 
it  rises  suddenly  to  reach  its  acme,  which  is  about 


1008  MALARIA  IN  MACEDONIA 

104°  less  than  an  hour  after  the  onset  of  the  fit. 
It  remains  at  this  high  level  for  two  and  a  half 
to  three  hours,  and  then  after  commencement 
of  the  sweating  stage  it  falls  to  100*8%  and  slowly 
returns  to  normal,  eleven  to  twelve  hours  after  the 
onset  of  the  fit.  The  ague  fit,  as  all  the  text- 
books state,  runs  its  complete  course  between  two 
meridians,  commencing  about  midday  and  ending 
before  midnight. 

1.  Principal  Types  of  Temperature  Curves 

The  ague  fits  are  generally  grouped  so  as  to 
constitute  tertian  or  quartan  fever,  ^  each  fit 
being  separated  from  the  following  by  an  apyrexial 
interval  of  one  day  in  the  case  of  tertian  fever  and 
of  two  days  in  that  of  quartan  fever. 

But  the  fit  may  remain  isolated  or  only  take 
place  at  longer  intervals,  of  about  a  week's 
duration.  On  the  other  hand,  it  may  form  an 
uninterrupted  series  of  quotidian  fits,  thus  con- 
stituting a  quotidian  intermittent.  Lastly,  the 
temperature  curve  in  secondary  paludism  some- 
times shows  a  very  irregular  character. 

(1)  Tertian  intermittent  fever. — This  is  the 
typical  curve  of  secondary  paludism :  the  fit  takes 
place  every  two  days  with  an  interval  of  thirty- 
six  hours  of  normal  temperature.  It  should  be 
noted,  however,  that  this  interval  of  forty-eight 
hours  between  the  onset  of  each  fit  may  be  pro- 

'  We  sliall  not  t?ive  a  description  of  quartan  fever,  which  has 
not  been  found  hitherto  in  Macedonia,  and  which  we  have 
only  seen  in  persons  coming  from  Algeria. 


SECONDARY  PALUDISM 


1009 


longed  or  shurtened  (forty-seven  to  forty-nine 
hours)  according  to  the  individual.  This 
peculiarity,  to  which  Italian  writers  have  drawn 
attention,  is  of  importance  in  determining  the  exact 
moment  for  administering  the  dose  of  quinine  for 
cutting  short  the  fit. 


Oatts 

Janvier  J 917 

20 

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22 

23  24 

V  25    21 

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Fig.  13. — Secondary  paludism.     Tertian  intermittent  fits. 


The  temperature  curve  of  tertian  intermittent 
fever  may  vary  considerably  in  length  according 
to  the  progressive  immunization  of  the  organism 
and  its  resistance.  The  diminution  in  vitality 
of  the  parasite  is  also  expressed  by  a  diminution 
in  the  intensity  of  the  successive  fits.  Lastly, 
quinine  treatment  is  almost  always  successful  in 
these  cases. 


1010 


MALARIA  IN  MACEDONIA 


(2)  Ague  fits  of  septan  type. — For  reasons 
hitherto  unexplained,  the  fits  instead  of  assuming 
the  tertian  type  may  only  recur  every  six  or  seven 
days,  even  in  the  absence  of  any  quinine  treatment. 
In  other  cases  they  recur  only  every  fortnight  or 
every  three  weeks,  giving  rise  to  what  has  been 
called  fits  of  the  bi-  and  tri-septan  type. 


^sfes 

Janvier  1917 

12 

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Fig.  14. — Secondary  paludism.     Septan  fits. 

(3)  Isolated  fits. — The  fits  may  even  appear  to 
be  absolutely  isolated.  After  apyrexia  for  one 
or  even  two  months,  on  the  occasion  of  fatigue 
or  a  chill,  and  sometimes  even  without  any  appreci- 
able cause  there  is  an  isolated  fit  which  will  not 
be  repeated  for  a  long  time. 

(4)  Quotidian  intermittent  fever. — This  is  due, 
as  Italian  writers  have  shown,  to  the  combination 


SECONDARY  PALUDISM  1011 

of  two  tertians  running  their  course  with  an  interval 
of  twenty-four  hours  between  them.  They  are 
caused  by  the  evolution  of  two  generations  of 
parasites  developing  at  twenty-four  hours'  interval. 
There  is  a  febrile  attack  every  day  instead  of  every 
two  days,  but  as  the  first  begins  shortly  before 
midday  and  ends  before  midnight,  the  temperature 
in  the  morning  is  normal,  which  accounts  for  this 
type  of  quotidian  intermittent. 

Irregular  fever. — In  some  cases  the  tempera- 
ture curve  does  not  seem  to  correspond  to  any 
definite  tj^pe,  and  its  course  is  very  irregular.  But 
if  the  temperature  is  taken  at  least  four  times  a  day, 
it  will  be  found  that  the  fever  really  reproduces 
the  temperature  chart  of  a  quotidian  intermittent, 
whereas  if  the  temperature  be  taken  only  twice  a 
day  the  maximum  and  minimum  temperatures  are 
not  indicated. 


2.  Clinical  Syndromes 

The  clinical  manifestations  observed  in  the 
course  of  secondary  paludism  are  much  less  fre- 
quent than  in  the  period  of  relapses  and  second 
attacks  of  primary  paludism.  Their  gravity  is 
also  much  less.  It  is  undoubtedly  possible  to 
meet  with  the  same  visceral  syndromes  as  those 
which  we  described  in  primary  paludism,  but  they 
are  generally  much  attenuated,  and  in  actual 
practice  we  have  hardly  seen  more  than  three 
varieties,  viz.,  anaemia,  nervous  disorders,  and 
bilious  hsemoglobinuric  fever. 

Anaemia. — Anaemia,  which  was  one  of  the  most 


1012  MALARIA  IN  MACEDONIA 

important  visceral  manifestations  of  the  period 
of  relapses,  still  remains  one  of  the  principal 
phenomena.  But  it  never  attains  the  degree  of 
severity  or  assumes  the  pernicious  character  which 
it  has  during  the  period  of  a  malarial  epidemic. 
It  retains,  however,  the  same  clinical  and  hsema- 
tological  characters,  although  the  oedema  and 
haemorrhages  are  not  often  seen.  A  slight  degree 
of  icterus  is  the  only  phenomenon  which  is  fairly 
commonly  met  with,  its  outbursts  succeeding  those 
of  anaemia. 

Nervous  Disorders  are  not  exceptional.  They 
are  mainly  due  to  affection  of  the  peripheral  nerves 
and  are  neuralgic  in  nature.  Focal  lesions  of  the 
central  nervous  system,  however,  have  been  ob- 
served at  this  period  and  are  indicated  by  paresis 
and  motor  aphasia ;  affection  of  the  meninges 
is  revealed  by  lymphocytosis  and  even  haemorrhage. 
For  further  details  we  will  refer  the  reader  to  our 
previous  description. 

Bilious  H^emoglobinuric  Fever  * 
Bilious  hcemoglobinuric  fever  is  fairly  charac- 
teristic of  secondary  paludism.  Though  we 
have  observed  a  few  cases  at  the  height  of  an 
epidemic,  the  affection  is  most  frequent  when  the 
attacks  show  a  tendency  to  become  disciplined 
and  when  the  individual  is  no  longer  exposed  to 
fresh  inoculations. 

We  will  choose  as  the  type  for  our  description 

^  Armand-Delille,  Paisseau,  and  Lemaire,  Caracteres  de  la 
bilieuse  hemoglohinurique  chez  les  Paludeens  de  FArmee  de  t  Orient. 
Bull,  Soc.  Med.  Hop.,  June  15,  1917. 


SECONDARY  PALUDISM  1013 

the  bilious  haemoglobinuric  fever  which  we  observed 
in  winter  during  the  month  of  January. 

The  patient  is  almost  always  undoubtedly 
malarial,  and  is  more  or  less  anaemic  in  conse- 
quence. Periodically  and  according  to  a  fairly 
regular  rhythm  he  presents  isolated  febrile  attacks 
or  a  series  of  two  or  three  with  a  tertian  grouping. 
The  attack  of  bilious  haemoglobinuric  fever 
generally  breaks  out  in  place  of  the  expected  ague 
fit  on  the  day  foreseen  by  the  patient  and  his  doctor. 

The  individual  is  suddenly  seized  with  violent 
shivering,  severe  headache,  and  pain  in  the  loins. 
He  suffers  from  nausea  and  vomiting,  and  has  the 
same  malaise  as  during  each  of  his  ague  fits,  but 
in  a  more  intense  degree.  The  fever  also  rises 
higher  than  usual  and  exceeds  104°  F.  In  the 
two  or  three  hours  followmg  the  onset  of  the  attack, 
before  these  various  symptoms  have  had  time  to 
subside,  the  patient  suddenly  feels  a  desire  to 
urinate,  and  his  urine  is  red  and  blood-stained. 
The  following  specimen  passed  is  darker  and  of  a 
port-wine  colour.  The  patient  is  now  overcome  by 
a  general  feeling  of  lassitude  and  takes  to  his  bed. 

Icterus  sets  in  a  few  hours  after  the  bloody  urine 
has  been  passed.  It  is  rarely  limited  to  the 
conjunctivae,  but  extends  all  over  the  skin  and 
mucous  membranes,  getting  darker  during  the 
first  twenty-four  hours. 

Examination  of  the  viscera  shows  only  a  slight 
enlargement  of  the  spleen  which  was  already 
present  before  the  attack,  the  organ  just  reaching 
the  costal  margin  and  being  tender  on  pressure. 
The  liver   is  also   slightly  enlarged,  just  reaching 


1014  MALARIA  IN  MACEDONIA 

below  the  false  ribs  and  is  also  tender  on  pressure. 
The  course  of  the  affection  varies,  but  as  a  rule 
the  bilious  haemoglobinuria  of  the  secondary  period 
ends  in  recovery.  The  following  day  the  patient's 
general  condition  is  already  improved,  and  he  is 
less  febrile,  though  he  still  has  some  anorexia,  slight 
headache,  lumbar  pain,  and  a  feeling  of  lassitude ; 
on  the  following  day  the  temperature  returns  to 
normal,  but  the  attack  still  persists  and  gradually 
subsides  in  a  week. 

The  urine  on  the  first  day  is  very  dark  and 
scanty,  its  quantity  not  exceeding  500-800  c.c.  It 
is  coloured  red  owing  to  a  large  quantity  of 
haemoglobin,  but  does  not  contain  red  cells.  Its 
amount  soon  increases  and  returns  to  normal  in 
the  course  of  the  following  days. 

The  haemoglobin  diminishes,  but  the  urine 
instead  of  getting  clearer,  becomes  icteric  and  full 
of  normal  bile  pigment.  Examination  of  the  urinary 
sediment  after  the  first  urine  has  been  passed  shows 
a  few  fragments  of  red  corpuscles  and  when  a  larger 
amount  of  urine  has  been  passed  much  cellular 
debris  and  even  epithelial  casts  are  found.  The 
kidney  ceases  to  be  blocked  and  desquamates 
after  having  allowed  the  haemoglobin  to  filter 
through. 

The  changes  in  the  blood  serum  present  a  similar 
cycle.  Examination  of  the  blood  made  at  the 
beginning  of  the  attack  shows  the  existence  of 
considerable  haemoglobinaemia,  the  blood  is  laked, 
and  the  following  day  the  serum  becomes  icteric 
and  the  free  haemoglobin  disappears.  The  study 
of  the  globular  resistance  yields  interesting  results  ; 


SECONDARY  PALUDISM  1015 

it  is  much  diminished  in  the  first  few  hours  of  the 
attack  of  bihous  fever,  the  red  cells  become  dis- 
solved in  normal  saline  solution,  and  then  their 
number  rises  rapidly  to  normal  (4'2  per  1000).  But 
the  jDatient  is  very  anaemic.  It  is  not  uncommon 
to  see  him  lose  a  million  red  cells  in  the  course  of 
an  attack. 

The  affection  may  present  two  different  modes 
of  evolution.  When  it  is  to  end  in  recovery,  which 
occurs  in  most  of  the  cases  in  secondary  paludism, 
the  urine  becomes  clear,  its  amount  increases,  the 
fever  falls,  and  all  the  discomfort  progressively 
subsides  ;  the  icterus  disappears  in  a  few  days. 
The  patient  remains  anaemic.  In  some  cases  the 
attack  of  haemoglobinuria  may  recur  after  a  period 
of  twenty-four  or  forty-eight  hours  in  which  the 
urine  remains  clear.  The  temperature  rises  again 
and  the  patient  again  has  urine  of  a  port- wine 
colour,  but  the  second  attack  is  generally  shorter 
and  convalescence  becomes  rapidly  established. 

In  fatal  cases  of  bilious  haemoglobinuria  death 
is  due  to  anaemia.  After  the  second  or  third  day 
there  is  suppression  of  urine  and  the  patient  develops 
uraemic  coma  or  more  frequently  a  gastro-intestinal 
form  of  uraemia,  which  may  last  for  a  week.  This 
severe  course  is  rare  during  the  secondary  period 
of  paludism,  and  is  much  more  frequent  during 
the  height  of  a  malarial  epidemic  from  July  to 
September.  This  form,  which  belongs  to  the  period 
of  relapses  of  paludism,  presents  a  more  severe 
course,  and  severer  functional  symptoms.  Ex- 
amination of  the  blood  shows  that  it  is  as  rich  in 
parasites  as  during  an  ague  fit. 


Chaptek  VI 
ASSOCIATION  WITH  OTHER  INFECTIONS 

Various  infectious  diseases  may  occur  in  the 
course  of  primary  and  secondary  paludism,  especi- 
ally typhoid  fever,  paratyphoid  fevers,  bacillary 
and  anaemic  dysentery,  and  recurrent  fever. 

Typhoid  fever. — The  subjects  in  our  field  of 
observation  had  generally  been  vaccinated  against 
typhoid  and  paratyphoid  fevers,  and  on  that 
account  association  of  inalaria  with  other  dieases 
was  rarely  observed.  In  the  cases  in  which  the 
co-existence  of  these  diseases  was  proved  by  bac- 
teriological examination  (positive  typhoid  blood 
culture  with  presence  of  haematozoa  in  the  smears), 
the  temperature  curve  and  the  course  of  the  disease 
were  dominated  by  the  more  powerful  infective 
agent,  in  this  case  the  haematozoon.^ 

In  non-vaccinated  cases,  on  the  contrary,  the 
clinical  appearances  in  this  association  of  diseases 
were  those  of  enteric  fever. 

Dysentery. — Bacillary  or  amoebic  dysentery  oc- 
curring in  a  malarial  subject  aggravates  his  case, 
causes  a  return  of  the  febrile  attacks  and  predisposes 
to  chronic  intestinal  lesions. and  malarial  cachexia 
of  the  secondary  period  of  paludism.     We  would 

^  Armand-Delille,  I'aisseau,  and  Lemaire,  Paludisme  de  I" 
invasion  en  Mucc'doiiie.     Bull.  Soc.  MM.  Hop.,  Marcli  3,  1916*. 

1016 


ASSOCIATION  WITH  OTHER  INFECTIONS  1017 

emphasize  the  necessity  of  a  simultaneous  ex- 
amination for  both  parasites,  hgematozoa  and 
amoebae,  in  the  blood  and  the  stools,  in  view  of  the 
possibility  of  a  dysenteriform  enteritis  of  purely 
malarial  origin ;  we  have,  indeed,  seen  cases  of 
true  dysentery  which  bacteriological  and  parasit- 
ological  examination  carried  out  under  the  most 
favourable  conditions  proved  to  be  connected 
neither  with  amoebiasis  nor  bacillary  dysentery, 
but  which  occurred  paroxysmally  in  malarial 
patients  whose  blood  was  infected  by  the  haema- 
tozoon. 

Recurrent  fever. — An  association  of  malaria 
with  recurrent  fever  may  possibly  take  place. ^ 
The  manifestations  of  secondary  paludism  being 
observed  in  Macedonia  in  the  winter  and  spring, 
it  is  easy  to  understand  its  co-existence  with  this 
affection  which  is  so  frequent  in  the  cold  season. 
Paludism  has  no  influence  on  its  course,  but  we 
have,  on  the  other  hand,  frequently  seen  malarial 
patients  have  tertian  fits  in  the  days  following  the 
relapse  of  recurrent  fever. 

^  Armand-Delille,  Gassin^  and  Lemaire^  Garacteres  de  lajievre 
r^currente  ohservee  a  V Armee  de  I'Orient.  Bull.  Soc.  Med.  Hop., 
June  15,  1917. 


Chapter  VII 


PARASITOLOGICAL  DIAGNOSIS 

We  shall  naturally  confine  ourselves  to  a  description 
of  the   essential   requirements   for   diagnosis,    and 

shall  only  mention  the 
technique  which  can  be 
carried  out  in  the  most 
rudimentary  laboratory. 
The  examination  for  the 
hsematozoa  of  malaria 
is  made  on  dried  and 
stained  blood  films.  It  is 
important  to  realize  that 
this  examination  must  be 
a  very  careful  one ;  on  the 
one  hand,  the  proportion 
of  positive  results  does 
not  exceed  40  per  cent., 
especially  in  subjects  on 
preventive  quinine  treat- 
ment, while,  on  the  other 
hand,  with  certain  ex- 
ceptions which  we  shall 
mention  later,  the  num- 


FlG.  15. — Method  of  making  a 
blood  film  (after  Langeron). 


ber  of  circulating  parasites  is  unusually  small. 
The  blood  intended  for  examination  should  be 
taken  either  from  the  lobe  of  the  ear  or  the  dorsal 

1018 


PARASITOLOGICAL  DIAGNOSIS        1019 

surface  of  the  finger  near  the  matrix  of  the  nail  ; 
the  skin  of  these  regions  should  be  very  carefully 
wiped,  as  the  mixture  of  sweat  with  the  blood  gives 
very  bad  preparations.  The  part  should  be  pricked 
with  a  pin  which  has  been  passed  through  the  flame 
and  a  very  minute  droplet  of  blood  should  be 
squeezed  out,  collected  on  a  very  clean  slide  near 
one  of  its  extremities,  then  spread  out  either  by 
a  sterilized  slide  or  a  visiting  card,  in  a  very  fine 
film,  and  lastly  dried  by  waving  it  rapidly  to  and  fro. 
After  having  carefully  wiped  the  region  which  has 
been  pricked  a  second  droplet  of  blood  should  be 
collected,  spread  out  and  dried  in  the  same  way  ; 
except  when  there  are  special  indications  two 
good  slides  are  sufficient  each  time  the  blood  is 
taken/ 

As  soon  as  the  slides  are  dry  they  should  be 
wrapped  up  in  paper  to  keep  them  from  flies,  which 
are  very  fond  of  blood  and  can  completely  change 
and  spoil  a  preparation  by  repeatedly  sucking  it. 
The  patient's  name  and  any  clinical  notes  of  interest 
should  be  written  on  the  wrapper.  All  the  methods 
of  staining  at  present  in  use  are  improvements  on 
the  processes  of  Laveran  or  Romanowski. 

The  preparations  are  easily  stained  by  Tri- 
hondeau's  method,  provided  the  recommendations 
are  strictly  adhered  to,  which  the  writer  took  care 
to  transcribe  on  the  notice  accompanying  the  bottle 
containing  the  stain.     It  runs  as  follows  : — 


^  r.   p.  95,  for  the  technique  of  the  so-called  ^'  thick  drop 
process." 


1020  MALARIA  IN  MACEDONIA 

Directions  for  using  Tribondeau's 

Bl-EOSINATE.^ 

"  Use  carefully  cleaned  slides  for  preparing  the 
films  ;  spread  the  blood  (or  organic  fluid)  in  a  thin 
layer  over  the  right  two-thirds  of  one  surface  by 
'  the  visiting-card  process  '  by  choice.  Dry  by 
shaking  in  the  air.  Do  not  use  heat  or  any  fixative. 
Mark  off  the  smear  on  the  left  by  a  line  with  a 
pencil  for  writing  on  glass. 

"  The  bi-eosinate  is  both  a  fixative  and  a  stain. 

"  For  fixing,  drop  0*2  c.c.  of  bi-eosinate  (about 
twelve  drops)  on  the  smear  with  a  special  pipette 
reserved  for  this  stain.  Place  the  slide  flat  on  the 
table,  cover  it  with  a  half  of  a  Petri's  capsule  to 
avoid,  especially  in  summer,  too  great  an  evapora- 
tion of  the  alcohol,  which  would  cause  immediate 
precipitation  of  the  stain  on  addition  of  water, 
and  then  leave  for  two  or  three  minutes. 

"  For  staining,  hold  the  slide  slightly  inclined, 
so  as  to  collect  the  bi-eosinate  on  one  of  the  long 
margins,  add  0*6  c.c.  of  distilled  water  (about  twelve 
drops)  to  the  stain,  mix  the  two  fluids  together  all 
over  the  surface  to  be  stained  by  a  few  rolling 
movements.  Then  put  the  slide  down  at  once  and 
don't  touch  it  until  the  staining  is  complete,  for 
moving  it  might  hasten  the  formation  of  a  pre- 
cipitate which  would  spoil  the  result.  Average 
time  required  for  staining  :   blood,  eight  to  twelve 

^  Avoid  the  use  of  any  trace  of  acid  or  base  (as  in  neutral 
stains).  Mount  without  a  cover-slip.  In  case  of  a  fine  pre- 
cipitate spoiling  a  permanent  preparation,  it  can  rapidly  be 
removed  with  80  per  cent,  alcohol,  and  the  coloration  restored 
by  pourino:  very  dilute  bi-eosinate  on  the  slide  (O'l  c  c.  to  2  c.c. 
of  distilled  water j. 


PARASITOLOGICAL  DIAGNOSIS,      1021 

minutes  ;  syphilitic  products,  twenty  to  twenty-five 
minutes. 

''  Finally,  wash  under  a  jet  of  distilled  water, 
without  first  employing  the  staining  fluid,  so  as 
to  avoid  fixation  of  the  surface  film  on  the  pre- 
paration. Shake  the  drops  off,  and  dry  rapidly 
with  cautious  use  of  a  flame." 

Borax-eosin-blue  stain. — We  warmly  recom- 
mend the  method  invented  by  Senevet,  which 
yields  uniformly  good  results,  and  possesses  the 
great  advantage  of  requiring  only  the  ordinary 
reagents,  methylene  blue  and  eosin. 

The  following  details  of  this  excellent  method, 
will,  we  think,  be  of  some  assistance  to  laboratory 
workers  : — 

1.  Prepare  the  two  solutions  A  and  B. 

A.  Methylene  blue,  1  part. 
Sodium  borate,  3  parts. 
Distilled  water,  100  parts. 

Leave  in  the  incubator  for  a  week  to  a  fortnight, 
or  three  weeks,  at  the  ordinary  temperature. 

B.  Eosin  in  water,  1  part. 
Distilled  water,  100  parts. 

Ready  for  use. 

Fix  the  films  in  90  per  cent,  alcohol,  or  better 
still  in  absolute  alcohol  for  at  least  five  minutes, 
and  after  complete  desiccation  of  the  alcohol,  place 
them  face  downwards  on  some  horizontal  supports 
(Petri's  capsule,  test  tubes,  etc.). 

Prepare  the  following  solution  in  a  very  clean 

glass  : — 

Distilled  water,  20  c.c. 

Solution  B,  1  drop. 


1022  .         MALARIA  TN  MACEDONIA 

Mix  well,  then  add 

Solution  A  (methylene  blue),  1-2  drops. 

3Iicc  ivell,  and  pour  at  once  on  the  films.  About 
1-2  c.c.  per  film  are  needed. 

Stain  for  2-3  hours,  wash  rapidly  under  the 
tap,  dry,  and  examine. 

N.B. — It  is  best  always  to  have  a  fresh  solution 
of  methylene  blue,  so  as  not  to  run  short,  if  the 
ordinary  solution  is  exhausted  or  has  lost  its 
staining  capacity. 

Always  use  the  same  pipettes  for  measuring  the 
drops  of  eosin  and  methylene  blue,  otherwise  the 
proportions  would  be  too  variable. 

It  sometimes  happens  that  after  having  yielded 
excellent  results  for  some  time  the  methylene  blue 
solution  stains  the  protoplasm  of  the  hsematozoa 
too  faintly.  Two  remedies  are  available:  1.  Use 
a  fresher  solution.  2.  Substitute  some  drops  of  a 
fresh  solution  for  some  of  the  old  solution. 

Make  sure  first  of  all  that  the  failure  is  not  due 
to  the  acidity  of  the  water  employed. 

Important  Note. — It  very  frequently  happens 
that  so-called  distilled  water  contains  more  or  less 
strong  traces  of  acid.  This  acidity  of  the  water  is 
the  cause  of  failure,  or  of  a  change  in  the  stain. 

To  avoid  this  accident,  use  water  which  is 
absolutely  neutral  or  even  by  preference  very 
slightly  alkaline.  Various  processes  are  to  be 
reconnnended  for  this  : — 

(a)  Boil  the  distilled  water  in  a  glass  flask. 

(b)  Use  rain  water  or  melted  snow. 

(c)  Add  drop  by  drop  to  the  distilled  water, 
increasing    quantities    of   a    5   per   cent,    solution 


PARASITOLOGIC AL  DIAGNOSIS        1023 

of  borate  of  soda,  or  a  1  per  cent,  solution  of 
carbonate  of  potash,  until  good  results  are  obtained 
(an  excess  of  alkalinity  has  the  drawback  of  in- 
juring the  structure  of  certain  elements,  especially 
the  nuclei  of  the  leucocytes). 

The  best  method  for  deciding  whether  distilled 
water  is  absolutely  neutral  is  that  described  by 
Langeron,  who  uses  as  a  reagent  the  alcoholic 
solution  of  haematoxylin  :  add  two  drops  of  a 
1  per  cent,  alcoholic  solution  to  10  c.c.  of  the 
water  to  be  tested,  and  add  drop  by  drop  a  solution 
of  1  per  cent,  sodium  carbonate  until  in  five  minutes' 
time  the  water  becomes  of  a  faint  but  definite  violet 
colour. 

{d)  Try  the  ordinary  water  available  and  which 
sometimes  gives  excellent  results.  If  the  staining  is 
successful,  the  following  results  should  be  obtained. 

1 .  Faint  staining,  a  drop  of  methylene  blue  (dark 
violet  colour  of  the  stain). 

The  blood  corpuscles  are  stained  pale  pink  or 
red.  The  nuclei  of  the  leucocytes  are  violet. 
The  neutrophils  show  very  fine  granulations  of  a 
violet  colour.  Those  of  the  eosinophils  are  of  the 
same  colour  as  the  red  cells,  sometimes  even  of 
a  lighter  pink.  The  protoplasm  of  the  mono- 
nuclears is  pale  blue,  and  that  of  the  lymphocytes 
dark  blue.  The  haematozoa  are  very  distinct  owing 
to  their  purple  nucleolus  and  pale  blue  protoplasm. 
The  forms  of  division  of  benign  tertian  have  a  darker 
protoplasm  and  more  intensely  coloured  nucleoli. 

In  the  sexual  forms  the  grains  of  pigment 
are  very  clearly  seen,  as  well  as  the  more  diffuse 
and    as    a    rule     less    highlv     stained    nucleolus. 


1024  MALARIA  IN  MACEDONIA 

Schiiffner's  dots,  which  are  sometimes  fine  and 
distinct  in  the  medium-sized  forms,  are  more 
distinct  in  the  sexual  forms  (gametes). 

2.  With  deep  staining.  With  two  drops  of  methy- 
lene blue  (blue  violet  colbur)  the  red  corpuscles 
appear  copper-coloured  or  lilac.  At  the  same  time 
all  the  staining  already  described  is  much  more 
intense,  especially  as  regards  the  nucleolus,  the 
protoplasm  of  the  hgematozoa,  and  Schiiffner's 
dots,  which  are  found  in  some  successful  pre- 
parations, even  in  the  corpuscles  invaded  by 
schizonts. 

The  last  stain,  although  less  pleasant  to  look  at 
on  account  of  the  coppery  appearance  of  the  red 
corpuscles,  is  nevertheless  to  be  recommended  for 
examining  the  hsematozoa,  their  discovery  being 
greatly  facilitated  by  the  intensity  with  which  they 
are  stained. 

Intermediate  staining  may  be  obtained  by  vary- 
ing the  proportions  of  the  methylene  blue  and  the 
eosin,  e.g.  by  mixing  three  drops  of  methylene  blue 
with  two  drops  of  eosin. 

Laveran's  panchroiiie.  —  Laveran's  panchrome 
may  also  be  recommended,  as  it  gives  excellent 
results,  but  we  have  not  personally  had  occasion  to 
use  it.^ 

We  may  also  mention  that  these  methods  ad- 
mirably stain  the  spirilla  of  Obermeyer,  and  the 
diagnosis  of  recurrent  fever  can  easily  be  made  on 
a  slide  intended  for  examination  of  the  haema- 
tozoa. 

I'he  examination  of  the  blood  films  enables  the 

^  V.  p.  95,  for  the  technique  of  this  method. 


PARASITOLOGICAL  DIAGNOSIS        1025 

three  haematozoa  of  malaria  to  be  distinguished 
from  one  another,  viz. :  the  Plasrnodium  vivax,  or 
agent  of  benign  tertian  ;  the  Plasmodium  precox  or 
falciparum,  the  agent  of  so-called  tropical  fever  or 
malignant  tertian ;  and  the  Plasm^odium  malarice, 
the  agent  of  quartan  fever.  Sometimes  two  of 
these  parasites  will  be  found  to  be  associated. 
We  will  now  describe  their  distinctive  characters. 


Diagnostic  Characters  of  Haematozoa 
1.  Plasmodium  vivax 

The  Plasmodium  vivax  is  the  parasite  most 
frequently  met  with  during  the  cold  season  (from 
December  to  June)  ;  in  summer,  on  the  contrary, 
it  was  found  in  less  than  20  per  cent,  of  the  cases. 
It  is  recognized  by  the  following  characters  : — 

(a)  The  blood  corpuscle  invaded  is  usually  the 
seat  of  three  important  changes :  it  is  increased  in 
size,  decolorized,  and  sprinkled  over  with  small 
violet-red  granulations  known  as  Schiiffner's  dots. 

{h)  The  parasite  itself  appears  in  four  different 
aspects,  according  as  it  is  young  (schizont),  adult 
(amoeboid  body),  in  course  of  schizogonic  division 
(rosette  body),  or  in  the  state  of  a  gamete  (macro- 
and  microgametocytes).  Specimens  of  each  of 
these  stages  are  frequently  found  in  the  same 
preparation. 

(c)  The  schizont,  a  young  form  of  the  plasmodium, 
appears  in  the  form  of  a  small  ring  generally  ovoid 
rather  than  rounded.  At  the  narrowest  pole,  a 
small  mass  of  violet  red  represents    the    nucleus. 


1026  MALARIA  IN  MACEDONIA 

EXPLANATION  OF  PLATE 

Plasmodium  vivax  (Var,  tertiana  Laveran). 

1.  Young  schizont  (sporozoite  just  penetrating-  the  corpuscle). 

2.  Schizont. 

ii.  Amasboid     body     in     an     enlarged     corpuscle     presenting 
Schiiifner's  dots. 

4.  Amof.boid  body  in  course  of  segmentation  in  a  much  enlarged 

corpuscle. 

5.  Rosette  body. 

6.  Young  7naerogamete. 

7.  Adult  macrogamete. 
8:  Microgametoryte. 

8  bis.  Macrogamete  underg-oing  retrogressive  schizog-ony. 

Plasmodium  falciparum  (Var.  par va- Laveran). 

0.  Sporozoite  attached  to  a  corpuscle. 

10.  Two  schizonts  inside  a  corpuscle. 

11.  Schizont  in  a  corpuscle  presenting  Maurer's  dots. 

12.  Tkree  schizonts  in  a  corpuscle  with  Maurer's  dots. 

13.  Rosette  body. 

14.  Young  intracorpuscidar  gamete. 

15.  Adult  maci'ogamete  (crescent  type). 

16.  Adult  macrogamete  (microgametocyte). 

16  bis.   Gamete  possibly  undergoing-  retrogressive  schizogony. 

Plasmodium  malaria  (Var.  quartana  Laveran). 

17.  Yoitng  schizont  in  a  non-enlarged  corpuscle. 

18.  More  developed  and  pigmented  schizont. 

19.  Pear-shaped  .fchizont. 

20.  Old  schizont,  much  pigmented. 

21.  Schizont,  undergoing  segmentation. 

22.  Daisy  body. 

23.  Macrogamete. 

24.  Microgametocyte. 

Red  Corpusclks  (Haematoblasts  and  leucocytes). 

{a)  Red  corpuscle  and  hcematoblast. 

(b)  H(ematoblast  in  a  red  corpuscle  simulating  a  schizont. 

{c)  Red   corpuscle    presenting    artificial    granules   (precipitated 

colouring  matter),  with    a    haematoblast   on    its   margin 

(cause  of  error). 
(d)  Nucleated  red  corpuscle. 

{e)  Polymorphonuclear  leucocytes  with  neutrophil  granulations. 
(_/')  Dejbnned  mononuclear  leucocytes, 
(g)  Melanijerous  leucocytes  with  some  azurophil  granules. 


Malaria    Parasites. 


Tribondeau's     Stain 


.ym 


5  7^ 

P/asm  o  dium    vivax . 


rSSr 


(  var.terNana  Lav. J 


^ 


f3 


P/asmodtum  fa/ciparum  z  prscox  . 
'- ' [var.parve  Lav.J 


o 

% 


#• 


2J  2<- 

P/asm odium  mafarlss  .  /">«/•.  (juartana  Lav.J 


/^^  corpuscles.  Hasmatobksts.  Leucocytes. 

P.Annancl-Delille.Def. 


PARASITOLOGIC AL  DIAGNOSIS       1027 

while  a  rounded  colourless  vesicle  situated  between 
this  nucleus  and  the  protoplasmic  zone  coloured 
blue,  which  limits  the  contours  of  the  schizont, 
represents  the  nutritive  vesicle. 

(d)  The  amceboid  body  is  merely  a  schizont  at  a 
more  advanced  stage  of  development.  The 
parasite  then  occupies  the  third,  the  half,  or  two- 
thirds  of  the  blood  corpuscle.  It  is  formed  of 
two  parts,  one  of  which  encloses  the  nucleus  sur- 
rounded by  a  clear  pink  zone,  the  nuclear  vesicle, 
while  the  other  is  constituted  by  a  mass  of  proto- 
plasm, containing  a  large  nutritive  vesicle  ramifying 
in  numerous  slender  pseudopodia,  the  arrangement 
of  which  varies.  In  these  forms  (large  forms) 
the  pigment  is  abundant  and  is  disseminated  in  the 
protoplasm.     Schiiffner's  dots  are  numerous. 

(e)  The  rosette  body,  when  well  formed,  appears 
as  a  rounded  mass,  filling  the  whole  corpuscle  and 
roughly  resembling  a  daisy.  It  is  constituted  by 
the  agglomeration  of  16-20  merozoites,  set  close 
together  round  a  mass  of  central  pigment.  Each 
merozoite  consists  of  a  large  nucleus  surrounded 
by  a  thin  zone  of  protoplasm. 

Side  by  side  with  the  typical  rosette  bodies,  less 
advanced  divisional  forms  are  to  be  found,  in- 
termediate between  the  preceding  and  the  amoeboid 
bodies  from  which  they  are  derived.  The  parasite 
is  rounded  as  if  it  were  contracted,  its  protoplasm 
stains  a  deeper  blue,  the  pigment  is  spread  out  into 
wavy  lines,  the  nucleus  is  divided  into  two  or 
three  or  more  distinct  portions,  and  the  nutrient 
vesicle  has  disappeared. 

(/)  The  gametes,   or  more   strictly   speaking  the 


1028  MALARIA  IN  MACEDONIA 

gametocytes  (for  the  transformation  into  sexual 
elements  will  only  take  plaee  in  the  alimentary 
canal  of  the  mosquito),  arc  easily  recognizable. 
Some  which  are  in  process  of  formation  (young 
gametocytes)  are  still  enclosed  in.  the  corpuscles, 
while  the  others  which  are  mature  are  free  in  the 
blood. 

The  young  gametocytes  which  are  still  enclosed 
in  the  corpuscles  are  ovoid  or  polygonal  ;  their 
nucleolus  is  very  large  but  of  loose  structure  ;  the 
protoplasm  is  deeply  coloured  and  does  not  show  a 
nutritive  vacuole,  but  contains  numerous  elongated 
pigment  granules.  The  mature  gametocytes  are 
big  rounded  elements,  twice  as  large  as  a  red 
corpuscle.  Their  nucleus  is  of  considerable  size  ; 
their  protoplasm  contains  numerous  pigment 
granules  arranged  like  needles.  The  macro- 
gametocytes  or  future  female  elements  can  be 
differentiated  by  their  nucleus  being  rounded  and 
presenting  a  granular  structure  and  the  pigment 
being  uniformly  distributed  over  the  protoplasm. 
The  pigment  often  predominates  round  the  nucleus  ; 
the  protoplasm  is  more  faintly  stained. 

It  is  important  to  realize  that  : — 

1.  The  Plasmodium  vivax  is  almost  constantly 
found  in  the  peripheral  blood  during  the  febrile 
attacks  and  generally  in  large  quantities.  2.  In 
the  intervals  it  is  still  frequently  present. 
3.  Although  the  parasitic  forms  found  are,  generally 
speaking,  different  according  to  the  stage  of  the 
attack  (the  rosette  body  during  the  attack,  and 
the  schizont  and  amoeboid  body  before  it),  and 
the  gamete  during  prolonged  periods  of  apyrexia, 


PARASITOLOGICAL  DIAGNOSIS       1029 

as  a  rule  a  mixture  of  all  the  forms  will  be  found  in 
various  proportions  in  the  same  preparation. 


2.  Plasmodium  falciparum  (Precox) 

The  Plasmodium  falciparum  is  essentially  a 
parasite  of  the  haematopoietic  organs  ;  its  presence 
in  the  peripheral  blood  is  far  from  constant,  even 
during  the  febrile  attacks  (35-40  per  cent,  of 
the  cases)  ;  as  a  general  rule  it  is  found  in  very 
small  numbers  in  the  blood.  The  preparations 
must  therefore  be  examined  for  a  long  time  before 
concluding  that  the  haematozoon  is  absent. 

The  parasitic  forms  found  in  the  blood  differ 
complet-ely  according  as  the  patient  is  suffering 
from  an  ordinary  febrile  attack  or  a  pernicious  one. 

A.  In  the  course  of  the  ordinary  forms  of  tropical 
paludism  the  forms  met  with  in  the  blood  belong 
to  two  types  only  ;  the  schizont  and  the  gamete. 
During  the  febrile  attacks  either  the  schizonts  are 
found  alone  or  the  schizonts  and  gametes  simul- 
taneously ;  in  the  interval  between  the  attacks 
only  the  gametes  are  found.  The  appearance  of 
schizonts  at  this  period  should  indicate  that  a 
relapse  is  imminent. 

{a)  The  schizont  of  Plasmodium  falciparum  is 
to  be  recognized  by  the  following  characters :  The 
corpuscle  which  it  invades  is  not  enlarged,  it  is 
not  decolorized,  but  on  the  contrary  often  shows 
a  slight  overstaining  (copper  tint)  ;  it  does  not 
contain  Schiiffner's  dots.  The  larger  and  irregular 
granulations  described  by  Maurer  often  seem'to  be 
absent  or  at  least  only  to  be  brought  into  view  by 


1030  MALARIA  IN  MACEDONIA 

special  stains.  The  parasite  itself  often  appears 
in  the  form  of  a  small  ring,  consisting  of  a  very  thin 
band  of  protoplasm  and  surrounding  an  achro- 
matic zone  ;  at  one  point  the  ring  is  occupied  by 
a  grain  of  chromatin  stained  a  bright  red  and  con- 
stituting the  karyosome.  Frequently  this  nucleus 
is  double,  each  grain  being  connected  with  the 
other  by  a  very  thin  filament  of  chromatin.  The 
absence  of  any  pigment  in  the  schizonts  of  Plas- 
modium  falciparum  is  the  rule. 

(h)  The  gametes  have  a  characteristic  form. 
They  are  the  crescents.  They  are  constituted  by  a 
membrane  with  a  double  wall,  fairly  visible  proto- 
plasm  and  pigment.  The  latter  is  sometimes 
grouped  in  the  centre  of  the  crescent  forming  a  mass 
which  masks  the  nucleus  (macrogametocytes),  or 
on  the  contrary  disseminated  irregularly  through- 
out the  extent  of  the  element ;  the  nuclear  chro- 
matin is  then  visible  in  the  form  of  filaments 
(microgametocytes,). 

Side  by  side  with  non-pigmented  schizonts  which 
predominate  and  sometimes  infest  in  large  numbers 
the  same  corpuscle,  and  the  crescents  which  are 
often  present,  we  may  also  find  :  1.  pigmented 
schizonts  of  a  larger  size  than  the  preceding ; 
2.  rosette  bodies  generally  with  fourteen  mero- 
zoites  ;  3.  bodies  which  occupy  an  intermediate 
position  between  the  schizonts  and  the  rosette 
bodies,  or  between  the  schizonts  and  the  gameto- 
cytes ;  they  are  rounded  elements  with  deeply 
staining  protoplasm,  and  a  large  double  nucleus 
enclosing  several  thick  grains  of  pigment. 


PARASITOLOGIC AL  DIAGNOSIS        1031 

3.  Plasmodium  malaria 

The  Plasmodium  malarice,  the  agent  of  quartan 
fever,  is  quite  exceptional.  It  is  usually  found 
fairly  easily  in  the  blood,  either  during  the  ague  fits 
or  in  the  interval.  As  in  the  case  of  Plasmodium 
vivax,  the  forms  found  in  the  same  preparation 
usually  belong  to  different  stages  of  evolution. 

The  corpuscles  invaded  are  not  increased  in 
size  ;  they  are  not  decolorized  and  do  not  contain 
granulations.  The  parasite  appears  iathe  following 
forms,  all  of  which  possess  the  common  feature  of 
being  clearly  visible  owing  to  the  intensity  of  the 
staining  of  the  Plasmodium  malarice  which  can  be 
stained  much  more  readily  than  the  other  haema- 
tozoa. 

{a)  The  young  schizonts  are  annular  with  a 
thick  crown  of  protoplasm  and  pigmented.  Sub- 
sequently they  become  elongated  in  the  form  of 
a  thong,  a  narrow  band,  or  a  pear.  Their  out- 
lines are  very  definite,  the  nucleolus  is  large  and 
elongated,  and  the  protoplasm  dark  blue. 

(h)  The  amoeboid  bodies  are  quadrangular  in 
the  form  of  a  rectangular  body.  The  nucleolus 
is  usually  elongated,  the  protoplasm  contains 
abundant  pigment  in  the  form  of  large  granules, 
which  frequently  have  a  linear  distribution,  forming 
a  border  round  the  parasite.  The  slanting  quad- 
rangular form  is  not  constant,  for  some  forms  are 
rounded. 

(c)  The  rosette  bodies  formed  of  6-12  merozoites 
show  a  remarkable  regularity  resembling  a  daisy 
in  appearance. 


1032 


MALARIA  IN  MACEDONIA 


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PARASITOLOGICAL  DIAGNOSIS        1033 

(d)  The  gamctocytes  are  ovoid,  richly  pigmented, 
and  contain  a  large  nucleus.  The  macroganieto- 
cytes  have  a  much  darker  protoplasm  than  that 
of  the  microgametocytes.  The  following  table 
shows  the  various  differential  characters  of  the 
three  plasmodia  of  malaria. 

The  examination  of  a  specimen  of  blood  should 
mean  more  than  a  search  for  the  parasites  of 
malaria.  It  is  advisable  also  to  investigate  two 
haematological  signs,  the  presence  of  which  is 
important  and  serves  as  a  guide  to  diagnosis  in 
the  absence  of  the  parasites.  These  two  signs  are  : 
1.  mononucleosis,  which  is  especially  frequent  at 
the  end  of  an  ague  fit  or  in  the  interval  between  two 
fits ;  2.  the  presence  of  melaniferous  leucocytes, 
which  is  not  found  till  late  and  requires  careful 
investigation,  as  the  number  of  melaniferous 
leucocytes  is  limited. 


The  Thick  Drop  Process.  If  it  is  desirable  to  make  a  rapid 
examination  for  rare  elements^  especially  crescents,  the  '^'^  thick 
drop  process/^  advocated  by  Leishman,  can  be  employed  with 
advantage.  Put  3-5  droplets  of  blood  on  the  slide  without 
making  a  film  of  them,  but  leave  them  to  spread  out  spon- 
taneously with  a  diameter  of  about  5  millimetres.  Dry,  then 
hccmolyze  the  preparation  in  distilled  water;  the  red  cells 
become  dissolved,  while  the  leucocytes  and  parasites  remain 
intact.  Dry  again,  and  stain  by  one  of  the  methods  indicated 
below. 

The  elements  are  generally  less  finely  differentiated,  and  the 
schizonts  are  less  definite  in  outline,  but  a  trained  eye  can 
easily  recognize  them  among  more  or  less  well-stained  leucocytes. 
The  process  enables  a  few  parasites  to  be  found  readily  in  a 
relatively  larger  quantity  of  blood. 

Laveran^s  Panchrome  Stain.  —  Technique  :  Do  not  fix  the 
smear.     Spre.id  the  undiluted  panchrome  over  the  slide  to  be 


1034  MALARIA  IN  MACEDONIA 

stained.  Cover  the  slide  to  prevent  evaporation.  Leave 
three  minutes  for  fixation  ;  then  turn  the  slide  over,  with  the 
surface  to  be  stained  downwards,  in  a  capsule  (Laveran's  or 
Petri's),  containing  the  quantity  of  distilled  water  corresponding 
to  the  quantity  of  panchrome  used.  Shake  at  once,  so  as  to  get 
a  good  mixture.  Leave  for  fifteen  to  twenty  minutes  according 
to  the  elements  to  be  stained.  Wash  in  plenty  of  water.  Dry 
between  two  cigarette  papers.     Never  use  heat  for  drying. 

The  panchrome  may  be  more  diluted,  in  which  case  the 
time  of  staining  should  be  prolonged.  The  staining,  for 
instance,  may  take  twelve  hours  (a  whole  night),  in  a  5  per  cent, 
solution,  but  in  that  case,  the  preparation  must  first  be  fixed 
ten  minutes  in  absolute  alcohol. 

It  is  essential  that  the  distilled  water  should  be  absolutely 
neutral. 


I 


Chapter  VIII 

TREATMENT  ^ 

The  various  forms  of  treatment  for  malaria  differ 
according  as  the  disease  is  primary  or  secondary. 

I.  Primary  Paludism 

Generally  speaking,  whatever  the  clinical  forms 
assumed  by  the  febrile  attacks,  the  irregular 
succession  of  which  constitutes  primary  paludism, 
the  principal  feature  of  the  treatment  at  this  time 
should  he  the  energetic  administration  of  quinine. 

The  medical  officer  should  realize  that  summer 
malaria  in  Macedonia  is  a  formidable  disease, 
against  which  the  doses  of  quinine  usually  employed 
elsewhere  are  ineffectual.  Their  failure  is  due  to 
many  causes,  viz.,  the  nature  of  the  pathogenic 
agent-  which  in  more  than  85  per  cent,  of 
the  cases  is  the  Plasmodium  falciparum ;  the 
hsematozoon,  which  offers  the  most  resistance 
to  quinine ;  the  multiple  inoculations  with  the 
parasite  due  to  the  enormous  number  of  the 
Anopheles  ;  and,  lastly,  the  varied  conditions,  such 
as  climatie,  fatigue,  and  physical  overwork,  which 
weaken  the  resistance  of  the  organism. 

^  P.  Abraini,  Le  Paludisme  pninaire  en  Macedoini  et  son  traite- 
ment.  Presne  medicale,  March  22,  1917,  niid  Bud.  Soc.  Med. 
Hop.,  Paris,  March  12,  1917. 

1035 


1036  MALARIA  IN  MACEDONIA 

The  aim  to  be  pursued  in  treating  primary 
paludism  is  essentially  different  according  as  one 
is  dealing  with  a  first  attack  of  fever  (paludism 
in  its  first  invasion),  or,  on  the  other  hand,  sub- 
sequent attacks  which  constitute  relapses.  This 
distinction  in  our  opinion  is  all  important,  and  it 
is  necessary  to  emphasize  its  significance. 

During  the  first  invasion  the  doctor^s  principal 
mm  should  be  to  prevent  the  formation  of  gametes. 
These  never  appear  before  the  eight  or  tenth  day 
of  the  disease.  Their  presence  in  the  organism 
entails  two  serious  consequences.  In  the  first 
place,  they  are  the  only  forms  of  the  parasite  which 
are  capable  of  propagating  the  haematozoa  after 
absorption  by  the  mosquito.  They  are,  therefore, 
the  only  source  of  a  malarial  epidemic  ;  without 
gametes  there  would  be  no  social  paludism. 
Secondly,  those  forms  which  are  particularly 
resistant  to  quinine  tend  to  make  the  disease 
chronic  by  giving  rise  to  fresh  generations  of 
parasites,  which  are  the  source  of  relapses.  With- 
out gametes  there  would  be  no  individual  paludism. 
Before  the  formation  of  gametes  mal&,ria  is  an  acute 
disease  which  can  be  sterilized  by  quinine.  After 
the  formation  of  gametes  malaria  becomes  a  chronic 
disease,  the  cure  of  which  requires  a  very  long  time 
as  a  rule. 

In  dealing,  therefore,  with  the  treatment  of 
primary  paludism,  we  must  discuss  successively  : 
1.  The  attack  in  its  first  invasion.  2.  The  period 
of  relapses. 

I.  Paludism  in  its  first  invasion. — The  treat- 
ment of  the  attack  in  its  first  invasion  should  be 


TREATMENT  1037 

early  and  intensive ;  early,  because  the  sooner  the 
administration  of  quinine  begins,  the  greater 
are  the  chances  of  kilHng  the  parasites  before 
they  have  had  time  to  change  into  gametes,  and 
intensive,  because  small  doses  of  quinine  favour 
the  development  of  these  resisting  forms. 

After  the  patient  has  been  given  a  saline  pur- 
gative (30-40  gm.  of  sulphate  of  soda),  repeated, 
if  necessary,  on  the  following  days,  3  grammes 
of  quinine  a  day  should  be  given  throughout  the 
duration  of  the  febrile  attack. 

Two  questions  have  to  be  discussed  from  this 
point  of  view  ;  first,  that  of  the  manner  of  ad- 
ministration of  this  dose  ;  secondly,  that  of  the 
time  when  it  should  be  given. 

(1)  Mode  of  administration  of  quinine. — The 
physician  has  three  principal  modes  of  adminis- 
tration at  his  disposal,  ingestion,  intramuscular 
injection,  and  subcutaneous  injection.  As  regards 
intravenous  injection,  it  remains  necessarily  an 
exceptional  process,  which  can  only  be  used  in 
certain  hospitals  and  particularly  severe  cases,  like 
pernicious  attacks.^ 

Ingestion  of  quinine  takes  place  either  in  the 
form  of  tablets,  or  by  preference  in  solution  (e.g. 
quinine  hydrochloride  10  gm.,  water  400  gm.,  each 
tablespoonful  containing  50  gm.  of  quinine).  After 
taking  the  drug  the  patient  may  be  given  a  quantity 
of  fluid  (hot  tea,  weak  coffee,  ptisan,  or  lemonade) 
to  diminish  the  irritating  action  of  the  quinine  on 
the  digestive  mucous  membrane. 

Ingestion    should    be    reserved    for    mild    cases, 
^  V.  Carnot  and  De  Kerdrel,  Paris  medical,  December  1916. 


1038  MALARIA  IN  MACEDONIA 

in  which  gastric  symptoms  (vomiting)  or  intestinal 
symptoms  (diarrhoea)  are  absent. 

It  is  chiefly  indicated  during  the  last  days  of 
the  febrile  attack  at  the  commencement  of  de- 
fervescence. 

The  doctor  should  make  sure  himself  that  the 
quinine  so  prescribed  has  really  been  tak^n. 
Tanret's  reagent  readily  enables  the  drug  to  be 
detected  in  the  urine. 

Intramuscular  or  subcutaneous  injection  of 
solutions  of  quinine  constitutes  the  best  method 
of  treatment  •  of  paludism  in  its  first  invasion, 
provided  that  certain  strict  rules  are  observed,  the 
neglect  of  which  renders  the  method  illusory  or 
even  dangerous. 

a.  Choice  of  solutions. — The  great  objection  to 
the  ordinary  solutions  (solution  of  quinine  and 
antipyrine  or  quinine  and  urethane)  is  that  they 
are  hypertonic  from  excessive  concentration  of 
quinine.  Moreover,  the  solution  of  quinine  and 
antipyrine,  which  contains  0'30  gm.  of  antipyrine 
to  0'50  gm.  of  quinine,  leads  to  the  injection  of 
0'80  gm.  of  antipyrine  daily  into  patients  with  deli- 
cate kidneys  and  a  vascular  system  in  a  state  of 
hypotension.  Owing  to  their  hypertonic  nature, 
the  absorption  of  these  solutions  is  certainly  slower 
and  less  complete  than  when  given  by  the  gastric 
route  ;  and  this  defect  in  our  opinion  is  sufficient 
to  condemn  a  method  whose  chief  object  is  to  lead 
to  more  rapid  absorption.  Lastly,  each  injection 
often  gives  rise  to  a  painful  inflammatory  nodule, 
in  which  the  quinine  is  retained  sometimes  in- 
definitely ;     on    repetition    of    the     injection    the 


TREATMENT  1039 

caustic  action  of  the  quinine  renders  the  patient 
liable  to  necroses  and  more  or  less  extensive  and 
deep-seated  abscesses,  which  are  very  slow  in 
healing  after  they  have  been  incised. 

Diluted  solutions  of  quinine  should  be  employed, 
so  as  to  reduce  to  a  minimum  the  caustic  nature 
of  the  product  and  to  facilitate  its  rapid  absorption. 
Roux's  syringe  should  be  substituted  for  that  of 
Pravaz  in  giving  the  injections.  One  of  us  has 
recommended  the  use  of  the  following  two 
solutions  : — 

1.  Quinine  hydrochloride,  10  gm. 
Antipyrine,   1*50  gm. 
Distilled  water,  200  gm. 

2.  Quinine  hydrochloride,  10  gm. 
Urethane,  3  gm. 

Distilled  water,  200  gm. 
According  to  the  experience  of  the  inspector- 
general  Grail  and  Dr  Castellani  there  is  a  real 
advantage  in  sterilizing  solutions  of  quinine  by 
tyndallization,  as  sterilization  at  120°  C.  is  one  of 
the  chief  causes  of  the  necroses  seen  after  injection. 

In  order  to  check  the  depressing  action  of 
quinine  on  the  cardio-vascular  system  we  add  to 
the  above  solutions  before  injection  the  contents 
of  an  ampoule  of  a  milligramme  of  adrenalin  to 
each  30  c.c.  of  the  solution. 

h.  Technique. — Injection  of  quinine,  whether 
intramuscular  or  subcutaneous,  requires  most 
careful  antiseptic  precautions.  A  large  number  of 
complications  (abscesses  and  sloughing)  are  due 
to  neglect  of  this  elementary  rule.  The  instruments 
(syringes  and  needles)  should  be  sterilized  in  the 


1040  MALARIA  IN  MACEDONIA 

autoclave  or  by  prolonged  boiling.  The  needle 
should  be  at  least  5  cm.  long  and  should  be  sterilized 
after  each  injection.  The  operator's  hands  should 
be  carefully  washed,  and  the  patient's  skin  sterilized 
with  tincture  of  iodine  which,  it  should  be  noted, 
does  not  act  until  four  or  five  minutes  after  being 
applied. 

(a)  Intramuscular  injections. — Intramuscular  in- 
jection should  only  be  made  at  the  seat  of 
election,  i.e.  in  a  region  where  the  sciatic  nerve 
cannot  be  injured  directly  or  affected  by  inflam- 
mation. This  area  is  limited  above  by  the  iliac 
crest,  and  below  by  a  horizontal  line  passing  through 
the  upper  extremity  of  the  natal  cleft. 

The  needle,  which  should  be  at  least  5  cm.  long, 
should  be  plunged  by  itself  vertically  and  deeply 
into  the  body  of  the  muscle  ;  the  injection  should 
be  given  very  slowly,  and  as  soon  as  it  is  finished, 
the  needle  should  be  withdrawn  by  a  single  quick 
movement.  Injections  should  not  be  repeated  in 
regions  which  are  the  seat  of  nodosities  or  in- 
flammatory swelling. 

c.  Subcutaneous  injections.  —  A  subcutaneous 
injection  should  only  be  given  with  a  dilute  isotonic 
solution  of  quinine. 

It  should  only  be  given  in  the  regions  of  election, 
viz.,  the  back  of  the  throat,  the  flanks,  or  the 
abdomen. 

It  should  be  given  into  the  subcutaneous  cellular 
tissue,  as  penetration  of  the  fluid  into  the  dermis 
is  liable  to  cause  necrosis.  The  needle,  which  should 
be  at  least  5  cm.  long,  should  be  thrust  in  separately 
first  of  all,  and  it  is  only  after  it  has  been,  found 


TREATMENT  1041 

to  be  freely  movable  in  the  cellular  tissue  that  the 
syringe  is  fitted  on  and  the  injection  is  given  slowly. 
We  have  no  hesitation  in  giving  the  preference  to 
subcutaneous  injection  ;  when  performed  carefully, 
it  hardly  ever  has  any  complications. 

(2)  Time  for  administration  of  the  quinine. — 
The  three  grammes  of  quinine  should  be  given  in 
two  doses :  1.50  gm.  morning  and  evening  ivhen 
intramuscular  or  subcutaneous  injections  are  em- 
ployed ;  or  in  three  doses  (1  gm.  in  the  morning,  1  gm. 
about  noon,  and  1  gm.  in  the  evening),  when  they  are 
taken  by  mouth. 

No  account  of  the  law  of  the  hour  is  taken  in 
adopting  this  method.  This  law  is  inapplicable  to 
paludism  in  its  first  invasion,  as  seen  in  Macedonia  ; 
the  biological  factors  which  give  rise  to  it  were  not 
found  in  our  patients,  and  the  pharmaco-dynamical 
factors  which  possibly  justify  it  when  the  ordinary 
methods  of  treatment  are  in  use  do  not  hold  good 
when  isotonic  solutions  are  employed.  Each  of 
these  two  points  requires  further  consideration. 

Experiments  admitting  of  no  dispute  have 
established  that  quinine  is  most  active  on  the 
merozoites  which  are  derived  from  the  rupture  of 
the  rosette  bodies  (biological  conclusion).  As 
this  rupture  coincides  with  the  onset  of  the  febrile 
attack,  it  is  important  that  the  quinine  should  reafeh 
its  maximum  concentration  in  the  blood  at  this 
precise  moment. 

Investigations  carried  out  many  years  ago  for 
the  purpose  of  establishing  the  cycle  of  the 
absorption  of  quinine  proved  that  the  absorption 
reached  its  height  at  the  end  of  six  hours  (phar- 


1042  MALARIA  IN  MACEDONIA 

macodynamic  conclusion).  As  the  result  of  these 
two  conclusions,  the  following  law  was  established : 
quinine  should  be  given  from  six  to  eight  hours 
before  the  onset  of  the  attack.  This  is  the  law  of 
the  hour. 

This  law  is  only  applicable  to  exceptional  cases. 
Owing  to  the  large  number  of  infecting  bites  which 
are  usually  inflicted,  malaria;l  individuals  are 
carriers  of  several  generations  of  plasmodia,  which 
evolve  simultaneously  in  the  system,  each  accord- 
ing to  its  definite  cycle.  The  result  of  this,  as 
is  clearly  proved  by  examination  of  the  blood,  is 
that  parasites  of  very  different  ages  are  present 
in  the  organs  and  the  blood  at  a  given  moment. 
The  law  of  the  hour,  which  is  applicable  to  cases 
in  which  only  one  or  at  most  two  alternating 
generations  of  parasites  are  present,  cannot  and 
ought  not  to  be  observed  in  the  cases  which  we  have 
to  treat. 

Secondly,  the  pharmacodynamic  idea  of  the 
optimum  absorption  of  quinine  in  six  hours' 
time  is  perhaps  true  in  cases  of  administration  of 
the  drug  by  mouth  or  of  injection  of  hypertonic 
solutions,  but  it  is  quite  wrong  when  subcutaneous 
injections  of  isotonic  solutions  are  given.  Their 
absorption  is  extremely  rapid.  In  less  than  half 
an  hour  after  injection  the  patient  feels  the  effects 
of  quinine  intoxication,  and  in  less  than  an  hour  the 
destruction  of  the  circulating  plasmodia,  even  of 
the  adult  forms,  is  obvious,  as  can  easily  be  seen 
in  patients  whose  blood  literally  swarms  with 
parasites  of  all  ages. 

Lastly,  it  is  impossible  to  take  a  law  of  the  hour 


J 


TREATMENT  1043 

into  account  in  a  disease  in  which  the  febrile  attacks 
are  characterized  by  continuous  or  subcontinuous 
fever  without  any  perodicity  in  the  evolution  of 
the  paroxysms. 

II.  Period  of  Relapses  and  Second  Attacks 

The  malarial  subject,  in  whom  the  abortive  treat- 
ment of  the  first  invasion  has  failed  and  who  has 
consequently  become  a  gamete  carrier,  is  henceforth 
doomed  to  suffer  from  a  chronic  disease.  This 
disease  consists  of  a  more  or  less  close  succession 
of  febrile  relapses  due  to  the  production  of 
generations  of  plasmodia  derived  from  cystic 
germination  and  separated  by  intervals  of  apyrexia. 
Moreover,  in  addition  to  relapses,  there  is  the 
possibility  of  more  or. less  frequent  reinoculations. 
What  treatment  should  be  adopted  in  chronic 
primary  paludism — 

1.  During  the  febrile  relapses  ?. 

2.  During  the  intervals  of  apyrexia  ? 

A.  Treatment  of  relapses. — The  relapse  should 
be  attacked  energetically  by  quinine.  But  the 
doctor's  aim  should  no  longer  be  to  endeavour 
to  produce  an  immediate  sterilization  of  the  system, 
as  this  can  no  longer  be  obtained  in  most  cases. 
All  that  one  can  ask  of  quinine  is  that  it  should 
shorten  the  febrile  attack,  attenuate  its  effects,  and 
prevent  pernicious  attacks  by  destroying  as  large 
a  number  as  possible  of  generations  of  plasmodia. 
The  cure  of  the  disease  can  only  be  obtained  by 
successive  courses  of  treatment,  and  often  requires 
a  very  long  time. 


1044  MALARIA  IN  MACEDONIA 

The  treatment  varies  according  to  the  character 
of  the  relapse. 

1.  In  most  cases,  the  relapse  assumes  the  type 
of  remittent  continued  fever,  its  duration  varying 
from  four  to  six,  eight  or  ten  days.  The  subin- 
trant  attacks  which  constitute  it  do  not  show  any 
hourly  periodicity,  but  as  a  rule  the  febrile  maxima 
occur  in  the  second  half  of  the  night. 

(a)  When  the  fever  does  not  reach  a  high  level 
(104°  F.),  and  the  general  condition  remains  satis- 
factory ;  when  the  examination  of  the  blood  shows 
only  a  few  plasmodia  or  remains  negative,  we 
prescribe  2  gm.  of  quinine  (hydrochloride)  daily 
in  two  doses,  viz.,  0*50  gm.  about  8  a.m.  and  1*50 
gm.  at  about  6  p.m.  Unless  there  is  gastric  in- 
tolerance, which  resists  ipecacuanha  or  sulphate  of 
soda,  the  drug  is  given  by  mouth  in  solution  or  in 
cachets  until  defervescence.  Otherwise  we  have 
recourse  to  hypodermic  injections  of  isotonic 
solution.  In  every  case  adrenalin  in  doses  of  a 
milligramme  morning  and  evening  is  associated 
with  the  specific  treatment. 

(6)  When  the  febrile  attack  is  severe,  or  if  the 
examination  of  the  blood  indicates  a  large  number 
of  parasites,  we  raise  the  dose  of  quinine  to  3  gm., 
until  the  temperature  does  not  exceed  100*4°  F., 
which  occurs  as  a  rule  in  two  or  three  days.  These 
3  gm.  are  given  daily  subcutaneously  in  doses  of 
1*50  gm.  morning  and  evening.  We  then  lower  the 
daily  dose  to  2  gm.  given  by  mouth,  as  in  the 
previous  case. 

(c)  Lastly,  in  cases  of  'pernicious  attacks,  the 
course   to    be   taken   differs   according   as   we   are 


TREATMENT  1045 

dealing  with  an  algid  attack  or  an  attack  of  the 
comatose  type.  In  the  algid  attack  the  danger  lies 
not  in  the  invasion  of  the  parasites,  which  may  not 
even  be  present  in  the  blood,  but  in  the  sudden 
cardio-vascular  collapse.  In  such  cases  the  treat- 
ment urgently  required  is  intravenous  injection 
of  adrenalin  in  normal  saline  solution  (2  milli- 
grammes of  adrenalin  in  500  to  1000  gm.  of  normal 
saline).  Intravenous  injection,  which  is  the  only 
efficacious  method  in  subjects  in  whom  the  entire 
vascular  system  is  in  a  state  of  collapse,  and  in 
whom  no  absorption  by  the  subcutaneous  route 
can  be  hoped  for,  intravenous  injection,  we  say, 
has  enabled  us  to  save  four  out  of  six  of  our 
patients  ;  in  two  of  them  signs  of  apparent  death 
had  already  been  present  for  more  than  five  minutes ; 
the  injection  was  accompanied  by  artificial  res- 
piration and  recovery  took  place.  In  the  algid 
attack,  therefore,  treatment  by  quinine  is  of 
secondary  importance,  and  need  only  be  used  after 
the  above  treatment  has  been  instituted. 

In  the  comatose  attack  the  danger  comes  from 
the  presence  of  the  parasites  in  the  blood.  Septi- 
caemia was  a  constant  feature  in  our  patients,  and 
reached  such  a  degree  that  in  blood  preparations 
it  was  easier  to  count  the  number  of  healthy 
corpuscles  than  of  those  infected  by  the  Plas- 
modium  falciparum.  In  other  districts  comatose 
attacks  without  infection  of  the  blood  have  been 
repeated,  as  well  as  comatose  attacks  due  to  the 
Plasmodium  vivaoc,  but  we  have  not  personally 
come  across  such  cases.  All  our  cases  were  caused 
by  the  Plasmodium  falciparum,  and   presented   a 


1046  MALARIA  IN  MACEDONIA 

massive  septicaemia.  In  such  cases  treatment 
should  simultaneously  combat  the  septicaemia  by 
the  use  of  quinine,  and  its  general  effects  by 
means  of  revulsives,  cardiac  stimulants,  etc.  The 
necessity  of  administering  quinine  in  such  cases 
by  injections  is  generally  admitted  ;  rapid  action 
is  needed.  One  of  us,  after  four  trials,  abandoned 
the  intravenous  method,  as  when  performed  on 
subjects  with  hyperpyrexia  the  injection  caused 
phenomena  of  shock  which  it  seemed  advisable 
to  avoid.  We  make  use  of  subcutaneous  in- 
jections ;  1  gm.  of  quinine  being  given  on  ad- 
mission to  hospital,  1  gm.  four  hours  later,  and 
another  1  gm.  in  another  four  hours.  The  in- 
jections are  repeated  in  the  same  doses  until  the 
comatose  state  completely  disappears  ;  they  are 
then  reduced  to  two  a  day,  each  consisting  of  1  gm., 
until  recovery  takes  place. 

2.  In  some  cases,  which  are  much  less  frequently 
seen,  and  hardly  ever  until  the  infection  is  of 
several  months'  duration,  the  relapses  assume  the 
form  of  several  series  of  quotidian  attacks  separated 
by  periods  of  apyrexia  of  variable  duration.  These 
forms  generally  prove  very  difficult  to  treat.  It 
was  only  by  injecting  3  gm.  a  day,  in  two  doses  of 
\'bO  gm.,  and  from  the  onset  of  the  febrile  attack, 
that  we  succeeded  in  reducing  the  number  of 
attacks  to  two  or  three. 

Of  course  the  management  of  relapses  does  not 
merely  consist  of  treatment  by  quinine.  According 
to  the  predominance  or  association  of  certain 
symptoms,  it  may  also  be  necessary  to  treat  pul- 
monary, gastric,  intestinal,  or  hepatic  phenomena, 


1047 
TREATMENT 

which  import  a  special  physiognomy  to  each  febrile 
attack.  One  of  the  most  important  of  these 
associations,  both  as  regard  prognosis  and  treatment, 
is  in  our  opinion  dysenteriform  enteritis.  Owing 
to  its  extreme  prevalence  during  the  months  of 
September  and  October,  its  tenacity,  its  resistance 
to  ordinary  treatment,  such  as  quinine,  and  its 
frequent  relapses,  it  represented  one  of  the  most 
serious  complications  of  malaria  ;  it  prolongs  and 
aggravates  the  organic  dissolution  and  leads  to 
early  cachexia.  It  should  be  combated  as  soon 
as  it  appears.  One  of  us  has  shown  in  association 
with  C.  Foix  that  in  most, cases  ordinary  serum 
treatment  applied  early  constitutes  a  very  success- 
ful curative  method.  Injection  of  60-80  c.c.  of 
horse  serum  (anti-diphtheritic  or  anti-tetanic 
as  well  as  anti-dysenteric  serum),  repeated  if 
necessary  the  following  day,  may  cause  the  most 
acute  dysenteric  syndromes  to  disappear  in  forty- 
eight  hours,  and  reduce  the  stools  from  thirty  to 
forty  down  to  one  or  two  in  a  day. 

B.  Treatment  of  the  intervals. — As  soon  as 
the  relapse  is  over  we  suspend  the  administration 
of  quinine  until  the  following  relapse.  The  reasons 
which  determined  us  to  do  this  are  numerous. 
First  of  all,  quinine  treatment  carried  out  during 
the  period  of  apyrexia  with  the  object  of  pre- 
venting the  approaching  relapse  invariably  proved 
ineffective.  Whatever  the  daily  dose  of  quinine, 
its  method  of  administration,  and  the  duration  of 
the  cure,  we  never  prevented  the  return  of  the 
attacks,  but  they  always  occurred  during  the  course 
of  the  preventive  treatment.     Some  of  our  patients 


1048  MALARIA  IN  MACEDONIA 

took  regularly  every  evening  1  gm.,  1*50  gm.,  or 
even  2  gm.  of  quinine  in  solution  or  in  cachets, 
others  were  given  1*50  gm.  for  five  days,  and 
then  after  two  days'  interruption  resumed  the 
treatment ;  to  others  we  gave  2  gm.  every  two 
days,  and  in  others  the  preventive  treatment  was 
started  five  days  before  the  presumed  date  of  the 
return  of  the  fever,  but  in  every  case  the  attempt 
to  prevent  the  relapses  failed. 

Moreover,  there  seemed  to  us  to  be  no  doubt 
that  prolonged  use  of  quinine  in  doses  of  1  gm. 
and  above  presented  real  dangers.  Anorexia  and 
digestive  disturbances  set  in  rapidly,  and  inter- 
fered with  the  taking  of  nourishment  which  is  one 
of  the  essential  elements  of.  the  treatment,  while 
anaemia  and  a  tendency  to  oedema  increased  with 
the  prolongation  of  quinine  treatment. 

Lastly,  relapses  occurring  in  subjects  who  have 
been  taking  quinine  for  a  long  period  are  generally 
much  less  affected  by  larger  doses  of  the  drug,  just 
as  if  the  hsematozoon  had  really  acquired  resistance 
to  quinine. 

We  have,  therefore,  completely  abandoned  the 
administration  of  quinine  during  the  intervals 
between  the  relapses.  The  period  of  apyrexia  of 
varying  duration  which  follows  the  end  of  a  relapse, 
is  a  period  of  relative  immunity. 

Advantage  should  be  taken  of  it  to  repair  as 
quickly  as  possible  the  losses  of  the  organism  and  to 
enable  it  to  resist  the  following  attack.  Experience 
having  shown  that  relapses  are  more  frequent  and 
severe  when  the  patient  is  anaemic  and  exposed  to 
fatigue  and  privations,  rational  treatment  should 


i 


TREATMENT  1049 

comprise  :  1.  absolute  rest ;  2.  substantial  nourish- 
ment ;  3.  reconstitution  of  the  blood  by  iron  and 
arsenic.  An  all  important  precaution  must  be 
added,  viz.,  to  protect  the  patient  from  fresh 
virulent  inoculations  by  means  of  the  mosquito  net. 

In  those  rare  cases  where  the  mechanical  pro- 
tection provided  by  the  mosquito  net  is  not 
available,  it  is  obvious  that  between  the  relapses 
the  malarial  subject  should  obey  the  rule  of  pre- 
ventive quinine  treatment  (0'50  gm.-0'75  gm.  of 
quinine  per  diem). 

To  sum  up,  the  treatment  of  chronic  primary 
paludism  comprises  a  series  of  sterilization  cures 
by  quinine,  strictly  reserved  for  the  febrile  attack, 
and  alternating  with  tonic  cures  to  build  up  the 
system. 

The  treatment  of  primary  paludism  which  has 
become  chronic,  is  in  most  cases  only  a  palliative 
treatment ;  it  is  only  exceptionally  that  a  recovery 
from  the  disease  takes  place  in  a  country  infested 
with  malaria.  Rapid  improvement,  on  the  other 
hand,  takes  place  in  healthy  districts.  Early 
repatriation  of  the  patients  is  a  measure  the 
necessity  of  which  appears  to  admit  of  no 
discussion. 

II.  Secondary  Paludism 

In  winter  and  spring  malaria  changes  in  char- 
acter. The  febrile  attacks  assume  the  form  of 
frank  isolated  paroxysms  which  occur  with  a  certain 
periodicity,  being  sometimes  quotidian  and  some- 
times tertian,  or   septan,  bi-septan,   or  tri-septan. 


1050  MALARIA  IN  MACEDONIA 

Examination  of  the  blood  at  this  paroxysmal 
period  which  characterizes  secondary  paludism 
reveals  an  inversion  of  the  parasitic  formula ; 
preparations  show  that  the  Plasmodium  falci- 
parum, the  predominating  agent  of  aestivo- 
autumnal  malaria,  has  been  superseded  by  the 
Plasmodium  vivax,  the  principal  cause  of  the 
malaria  of  the  winter  and  spring,  a  season  when  the 
disease  is  much  less  dangerous  and  reacts  better 
to  quinine. 

We  will  confine  ourselves  to  a  description  of  the 
general  rules  of  a  treatment  which  has  long  been 
established.  The  treatment  applies  first  to  the 
ague  fits,  and  secondly  to  the  intervals. 

1,  Treatment  of  the  ague  fits. — The  ague  fit 
should  be  treated  energetically,  2  gm.  of  quinine 
as  an  ordinary  dose  should  be  given  in  the  twenty- 
four  hours.     These  2  gm.  may  be  administered  : — 

(1)  By  intramuscular  or  subcutaneous  injections  : 
1  gm.  in  the  morning  and  1  gm.  at  night. 

(2)  By  ingestion  (in  tablets  or  solution),  and  in 
that  case  one  must  always  make  sure  that  the 
dose  prescribtd  is  really  taken.  The  mode  of 
administrat  )n  oi  these  2  gm.  really  matters  little. 
Some  give  I  50  gm.  in  the  morning  and  1*50  gm. 
at  night,  others  gm.  in  the  morning  and  1  gm. 
at  night,  while  others  prefer  fractional  doses,  e.g. 
4  doses  of  0°50  gm.  or  even  0*25  gm.  eight  times  in 
the  twenty-four  hours. 

In  the  case  of  quotidian  attacks  the  adminis- 
tration of  quinine  should  be  continued  regularly 
until  the  fever  disappears,  andrm^the  case  of  tertian 
attacks  until  the   disappearance  of  the   series   of 


TREATMENT  1051 

ague  fits.  In  all  cases  the  treatment  should  be 
continued  in  the  same  doses  for  at  least  two  days 
after  the  commencement  of  final  apyrexia. 

2.  Treatment  of  the  intervals. — When  apyrexia 
is  established,  the  patient  should  undergo  dis- 
continuous quininization  according  to  Laveran's 
method  of  successive  treatments.  There  are 
various  forms  of  this  treatment ;  all  yield  the  same 
results.     The  following  are  some  of  the  formulae  : — 

(1)  One  day  of  quinine  and  one  day  of  rest,  one 
day  of  quinine  and  one  of  rest,  and  so  on,  for  six 
consecutive  weeks.  On  the  quinine  days  the  drug 
is  given  in  a  single  dose  of  1  gm.  or  1*50  gm.  by 
mouth  (in  tablets  or  solution),  or  in  two  doses 
(0'50  gm.  in  the  morning  and  0*50  gm.  or  1  gm.  at 
night)  or  in  four  or  five  doses. 

When  an  ague  fit  occurs  in  the  course  of  treat- 
ment, the  dose  is  raised  to  2  gm.  on  the  day  of  the 
fit  and  the  two  following  days. 

(2)  Job^s  method. — During  the  first  week  :  six  days 
of  quinine  and  one  day's  rest.  During  the  second 
week  :  five  days  of  quinine  and  two  days'  rest. 
During  the  third  week  :  four  days  of  quinine  and 
three  days'  rest.  During  the  fourth  to  the  eighth 
weeks  :    three  days  of  quinine  and  four  days'  rest. 

On  the  quinine  days  the  drug  is  ordered  in  doses 
of  1  gm.  (a  tablet  of  0*25  gm.  at  8  a.m.,  one  at  10 
a.m.,  one  at  noon,  and  one  at  2  p.m.). 

(3)  Carducc^s  method. 

1st  week. 

1st  and  2nd  day  of  apyrexia,  1  gm.  of  quinine 
daily. 


1052  MALARIA  IN  MACEDONIA 

3rd  and  4th  day,  no  quinine. 

5th  and  6th  day,  1  gm.  of  quinine. 

7th  day,  1'50  gm.  of  quinine. 

2nd,  3rd,  4th,  5th  and  6th  weeks. 

8th  day,  1  gm. 

9th,  10th,  11th,  12th  day,  no  quinine. 

13th-and  14th  day,  1  gm.  of  quinine. 

There  is  no  need  to  insist  on  the  advantage  of 
associating  with  quinine  treatment  absolute  rest, 
abundant  nourishment,  arsenic  and  iron. 

(4)  The  Italian  "  sterilizing  "  method. — The 
Itahan  medical  officers  advocate  the  following 
treatment : — 

1st  week. 

2  gm.  of  quinine  daily. 

2nd  week. 

One  day  of  rest,  followed  by  a  cold  bath,  then 
2  gm.  of  quinine  daily. 

Final  cessation  of  quinine  treatment,  followed 
by  a  cold  bath. 

If  this  bath  does  not  give  rise  to  another  ague  fit, 
the  patient  is  considered  to  be  cured. 

If  a  fresh  fit  occurs,  the  treatment  must  be 
started  again. 

In  view  of  the  intensity  of  malaria  in  Macedonia, 
Castellani  and  the  Italian  writers  have  recom- 
mended even  3  gm.  daily  during  the  first  few  days. 

RavauVs  method. — Ravaut  has  made  trial  of 
cacodylate  of  soda  and  obtained  interesting  results  ; 
but  it  has  to  be  employed  in  large  doses  (20-30  cgm. 
daily)  and,  of  course,  combined  with  quinine.     The 


TREATMENT  1053 

following  is  the  method  which  he  has  had  carried 
out  in  several  hospitals. 

A  subcutaneous  injection  of  0*20  or  0*30  gm.  of 
cacodylate  of  soda  is  given  daily  for  three  or  four 
days  running.  The  following  two  or  four  days 
2  gm.  of  quinine  in  cachets  are  to  be  taken  by 
mouth;  Then  the  injections  of  cacodylate  are  to 
be  resumed,  and  so  on  for  at  least  a  month,  without 
paying  any  attention  to  the  febrile  attacks. 

Lastly,  Ravaut,  in  view  of  the  signs  of  suprarenal 
insufficiency  which  he  found  almost  invariably 
present,  advocates  the  addition  of  adrenalin,  which 
is  very  efficacious  either  in  the  form  of  injections 
or  in  the  form  of  solution  (twenty  drops  daily  of  the 
one  in  1000  solution). 

This  treatment  can  be  carried  out  by  anyone, 
does  not  present  any  danger,  and  gives  very 
superior  results  to  those  obtained  by  quinine 
alone. 


INDEX 


Aaser,  anti-cholera  vaccine,  452 
Ahiitlie,  6().S. 

Al);lonion,  tetan\is localised  in,  late- 
app'^arinj;,  Henri  Bouiuet, 
772. 
Abdominal  musfular  contra'^tiiro 
in  pro;^iiosis  of  local  tetanus, 
842. 
pain  and  tenderness  in  typhoid 

fever,  30. 
pains  of  dysentery,  2-)'),  305. 
Abdoinino-thoracic   form    of    local 
tetanus,  811. 
case,  P.  L.  Marie,  811. 
development  of,  815. 
mode  of  entrance  in,  814. 
pathogenesis  of,  815. 
summary  of,  918. 
Abortive  typlioid  fever,  10. 
Abscess,  hepatic,  68. 

in    ainrebic    di'senterv,    301, 
305-306. 
Abscesses,  147. 
multiple,  40. 
subcutaneous,  79. 
Absorbent  wool,  654. 
Absorjjtion,  disorders  of,  in  cholera, 

386-387. 
Academv   of   Medicine,    535,    698, 

700. 
Accidental  InsuranceCoTnpany,520. 
Accidents,    in    intravenous    injec- 
tion, 661. 
operative,  150. 
Acid  nitrate  of  mercurv  in  syphilis, 

143. 044-645. 
Acne,  syphilitic,  578. 
Acneiform  syphilide,  578,  645. 
Active  syphilitic  treatment,  675. 
Acute  cirrhosis,  635. 
encephalitis,  635. 
meniiiy;o-m>'elitis,  586. 
polio-encephalitis,  63. 
Adenitis,  557. 


Adenopathy,  544. 

of  chancre  of  lip,  570. 
satellite,  544. 
Administration,    endermic    in    sv- 
philis,  600. 
of  m-Tcury,  intramuscular,  600. 
o''),iections  to,  602. 
intravenous,  609. 
Adrenaline,   use  of,   in  antitetanie 
sero-therapy,  861. 
with    quinine,    in    treatment    of 
malaria,  1053. 
Advice  as  to  hygiene  in  sypliilis,  666. 

to  hospital  patients,  678. 
Adynamic  typhus,  466. 
Affections  in  .syphilis  of  aurlitory 
nerve,  633. 
nervous,  585. 

sensory  and  arsenobenzol,  586. 
statistics      of      cutaneoua      and 

veneral,  505-506. 
treatment  and  tertiary,  643. 
visceral,  585. 
Affusions  in  typhoid,  133,  135. 
\fter-etTect      of     novarsenobenzo, 

injections,  628,  629,630. 
Age,  in  typhoid  fever,  a  predispos- 
ing factor,  170. _ 
and  vaccination,  275. 
average,  170. 
in  prophylaxis,  225. 
mortality  in  Paris,  171. 
Aged,  typhoid  fever  in,  16. 
Agents,  antiseptic,  in  syphilis,  593. 
\gglutination     test,    in     typhoid 

49, 116, 118. 
Ague,    administration    of    quinine 
in,  1050. 
in   secondarv   paludism   in   ma- 
laria, 1006. 
temperature  in,  1007. 
Aisne  Valley,  tetanus  in,  820. 


1055 


1056 


INDEX 


Albuminuria  in  malaria,  988. 
in  syphilis,  524,  588,  649. 
arsenobenzol  and,  635. 
cyanide  of  mercury,  664. 
in  typhoid,  vaccination  and,  275. 
Alcohol  as  a  tonic  in  typhoid,  143. 
compresses,  139. 
drinking  of,  in  syphilis,  667. 
in    antitoxic    treatment    of    te- 
tanus, 883. 
Alcoholic  patients,  severity  of  ty- 
phoid fever  in,  18. 
Alcoholism  and  cholera,  413. 
Algid   form   of   pernicious   attacks 
in  second   phase  of  primar 
■paludism  in  malaria,  1001. 
Alopecia,  syphilitic,  521,  581,  582. 
Altona,  Germany,  cholera  at,  433. 
Ambulatory   paratyphoid,    11,   93, 
180. 
treatment  in  syphilis,  690. 
Ammonium    persulphate,    destruc- 
tion   of    tetanus    toxin    by, 
848. 
Amoeba  coli,  316. 

dysentericae ,  318. 
encysted,  363. 
of  dysentery,  (See  Entamoeba.). 
Amoebic  dysentery,  305-310. 
chronic,  361. 

complications  of,  306-308. 
differential  diagnosis  of,  314. 
epidemiology  of,  359-368. 

contagion     in,     by  carriers, 
361-362. 
immediate,  362. 
indirect,  363. 
by  water,  364. 
encysted  amoeba  in,  363. 
vitality  of  amoeba  in,364. 
geographical  distribution  in, 

365. 
of  mixed  infections,  366. 
amoebo-facillary,  366. 
with  other  parasitis,  367. 
parasite  in,  359. 

animals  carriers  of,  360. 
localities  infected  by,  356. 
mode  of  entrance  of,  into 

body,  360. 
persistence  of,  361. 
j)oint     of     departure     of, 
form  body — excreta,  361. 
in  Europe,  362,  366. 
prophylaxis    of,    369.     (.See    also 

Dysentery), 
symptoms  of,  305. 

abdominal  pain  in,  305. 


Amoel^ic  dysentery,  symptoms   of, 
diarrhoea  in,  305. 
in  chronic  form,  306. 
of  complications  of,  306. 
abscess  of  liver  in,  307. 
peritonitis  in,  307. 
treatment  of,  326-328. 
Amoebic  hepatitis,  366. 
Amoeboid  body  in  malaria,  940. 

of  Plasmodium  malariae,  1031. 
of  Plasmodium  vivax,  1027. 
Amphibolic   stage    in   temperature 

of  typhoid  fever,  55. 
Amputations  in    treatment   of   te- 
tanus, 846. 
Anajmia  in  defaced  paludism,  1003. 
in  second  attacks  of  primary  in- 
vasions in  malaria,  969. 
haemorrhagic  form  of,  971. 
splenomeglaic  form  of,  971. 
typical  form  of,  969. 
with  hydraemia,  970 

early  appearance  7,  972. 
quinine  in,  972. 
with  icterus,  972. 

blood  examination  in,  973. 
in   secondary    paludism   in   ma- 
laria, 1011. 
progressive  pernicious,  971. 
Anaerobiosis.  848. 

Anaphylactic    shock    in    adminis- 
tration of  antitetanic  serum, 
767. 
Aneurism,  aortic,  in  syphilis, 635. 
Angina,  Vincent's,  571,  584. 
Anilarsinate  of  sodium,  612. 
Animals    as   paratyphoid   carriers, 
257. 
dysentery  in,  344. 
Anopheles  maculipennis,  in  Mace- 
donia, 947. 
mosquito  in  inoculation  of  ma- 
laria, 939. 
Antecedents  of   patients  and  sec- 
ondary syphilis,  547. 
Antimonial  cholera,  398. 
Antiparatyphoid  vaccination,  263 

et  seq. 
Antipyretic   drugs   for  use   in    ty- 
phoid fever,  140. 
Antipyrine  in  typhoid  fever,  140. 
Antiseptic  agents  in  syjihilis,  593. 
fluid,  654. 
soap  as,  689. 
Antiseptic  medication  in  typhoid, 
142. 


INDEX 


1057 


Antitetanic  serotherapy,  curative, 
872. 
cases,  746. 
injections  in  contact  with  wound 

in,  880. 
intra-arterial  injections  in,  877. 
intra-cerel^ral  injections  in,  878. 
intra-muscular  injections  in,  875. 
intra-nervous  injections  in,  879. 
intravenous  injections  in,  875. 
para-nervous  injections  in,  880. 
para-radicular  injections  in,  880. 
suli-arachnoid  injections  in,  878. 
subcutaneous  injections  in,  874, 

880. 
value  of,  872. 
Antitetanic  serum    in  prophylaxis 
against  tetanus,  852. 
anaphylaxis  followinj^:,  869. 
anti-anaphvhictic  measures  in, 
864-865. 
dosage  in,  870. 
efficacy  of,  865. 
history  of,  852. 
innocuousness  of,  858. 
preparation  of,  853. 
properties  of,  854. 
antitoxic,  854. 
prophylactic.  855. 

against     tetanus    infection, 
855. 

tetanic  toxin,  855. 
rules  of  injection  for,  867. 
salol  as  adjuvant  in,  871. 
symptoms  due  to  first  injection 
of,  858. 
emptions,  858. 
fatal,  860. 

serum  sickness,  S69. 
symptoms    due    to   re-iniection 
of,  861,  886. 
immediate.  861,869. 
general,  862. 
local,  861. 
late-appearing,  861,  870. 
with  sub-gallate  of    bismuth  in 
prophylactic    treatment    of 
wounds,  849. 
Antitoxic    treatment    of    tetanus, 
880. 
alcohol  in,  88.3. 
ascitic  acid  in,  884. 
Bottu's  mixture  in,  886.    • 
curbolic  acid  in,  880. 
mode  of  action  of,  882. 
results  in,  881. 
cholesterin  in,  884. 
ctjUoidal  metals  in,  883. 


Antitoxic     treatment  of    tetanus, 
hypochlorate  of  betain  in,  884. 
nervous  opotherapy  in,  884. 
salvansan  in,  883. 
sodium  persulphate  in,  885. 
Antitoxin,  (tetanus),  920,  923. 
Antityphoid  vaccination,  263  et  seq. 
compulsory,  242,  286. 
some  army  examples  of,  281. 
value  of,  226. 
Anti-venereal  struggle  in  Italy,  688. 
Aortic  aneurism,  635. 
Apert  and  Lhermitte,  pararadicu- 
lar     injections     of     anti-te- 
tanic serum,  880. 
Apes,  experiments  for  syphilis  on, 
689. 
tvphus  produced  in,  by  inocula- 
tion, 486-487. 
Aphasia   in   second    phase   of   pri- 
mary paludism  in  malaria, 
1000. 
in  syphilis,  585. 
in  typhoid,  63. 
Aphonia  in  second   phase   of  pri- 
mary paludism,  996. 
Aphthas,  583. 

Apoplectic  isolation  type  of  perni- 
cious attack  in  second  phase 
of  primary  paludism  in  ma- 
laria, 999. 
Apparatus,   intravenous  injection, 

653. 
Appearance  of  spirochaete,  552. 
Appetite  in  typhoid,  26. 
Apyretic  cases  of  typhoid,  12. 
Aqueous  solution   of  liiniodide  of 

mercury,  606,  609. 
Arabs,  susceptibility  of,  to  typhoid 

fever,  169. 
Armies,  anti-cholera  vaccines  used 
in,  452. 
cholera  in,  410-412. 
dysentery  in,  337-344. 
syphilis  in,  frequency  of,  503. 
leave  and,  513. 
origin  of  contagion  in,  509. 
scheme  for,  641. 
special  conditions  of,  591,  592. 

593. 
treatment  of,  at  the  front,  649. 
in    depots     and    sedentary 
services,  650. 
tvphoid   in,    contagion   in,    202, 
207. 
necessity  of  immediate  isola- 
tion in  suspected  cases,  232. 
prophylaxis  against,  242  et  seq. 


1058 


INDEX 


Armies,  typhoid    in,  statistics  in, 
15S. 
susceptibility  to,  15S,  172,  173. 
trench  life  and  its  dangers  in, 
250.    {Cf.  also  French  Army 
War,  and  War-time.) 
vaccination  in,  2G6,  280. 
febrile    reactions    following, 
271. 
typhus  in,  470-478. 
Arrhenate  of  mercury  in  syphilis, 

G12. 
Arsenic  in   treatment   of  syphilis, 
591,  593,  612. 
association  of  mercurv  and,  038, 

039,  040,  042,  043. 
galyl,  030. 
hectine,  030. 
luargol,  037. 

neosalvarsan  (novarsenobenzol) , 
(,S',?c  also  Novarsenobenzol.) 
71.5. 
salvarsan     (arsenobenzol),     013. 

{See  also  Arsenobenzol.) 
ulcerations  due  to,  557. 
Arsenical  cholera,  398. 
Arthropathies  in   bacillary  dysen- 
tery, 304. 
Arsenobenzol  in  syphilis,  543,  613, 
038,639. 
and  albuminuria,  635. 
(uitaneous  erui)tions  and,  635. 
deaths  from,  632. 
description  of,  612,  613,  614,  615. 
mercury  and,  634,  035. 
nervous  system  and,  632. 
neurotropism  of,  634. 
pseudo-chancre  and,  04,  500,  567. 
sensory  affections  and,  586. 
serious    accidents    in    treatment 
with,  631.    {See  also  Novar- 
senobenzol, 631.) 
Arterial    wave    in    typhoid,    char- 
acters of,  51, 
Arteries,  and  typhoid  fever,  44. 
Arteritis,  gonorrhoeal,  520. 
parietal,  45. 
typhoid,  44. 
Arthro-typhoid.  9. 
Articular  rheumatism,  102. 
Artificially  induced  lesions,  583. 
Asiatic     cholera.     {See     Cholera, 

Asiatic.) 
Ascitic  acid  in  antitoxic  treatment 

of  tetanus,  884. 
Asphyxia  in  cholera,  treatment  of, 

406. 
Ataxic  typhus,  466. 


Ataxo-adynamic  form  of  typhoid, 
12. 
of  typhus,  466. 
Atmospheric  condition?  in  develop- 
ment of  tetanus,  832. 
cold.  832. 
humidity,  832. 
Atoxyl  in  syphilis,  612. 
Atrophy  of  liver,  testicular  in  sy- 
philis, 531. 
yellow,  in  syphilis,  635. 
Attack    and    barrage    in    syphilis, 

treatment  b.v,  641. 
Attacking    treatment    in    syphilis, 

610. 
Attenuated  forms  of  local  tetanus 
with  slow  development  and 
prolonged  incubation,  817. 
pathogenesis  of,  817. 
symptoms  of,  817. 

facial  expression  in,  818. 
hyper-excitability    of    muscles 

and  nerves  in,  818. 
muscular  hypertonia  in,  818. 
summarj'-  of,  919. 
Atypical    forms    of    tetanus,    707. 

{See  also  forms  by  name.) 
Auditory    disturbances    in    second 
phase  of  primary  paludisra 
in  malaria,  997. 
hallucinations  in  syphilis,  633. 
nerve  labyrinth,  lesions  of,  586. 
Audry,  Charles.  526-599. 

and  insurance  statistics,  526. 
Audry's  suppositories,  599,  600. 
Austria,    epidemics   of   typhus   in, 

480. 
Austrian  Army,  in  European  war, 
cholera  in,  411. 
vaccination  against  cholera  in, 
452. 
Avitolysat  (Vincent's  vaccine) ,  122, 

151. 
Avignon,  epidemics   at,    242,    254, 
272  287,288. 

Baccelli,  608. 

Bacelli's    carbolic    acid    treatment 

of  tetanus,  880. 
Bacillary  dysentery,  298-304. 
clinical  forms  of,  300. 

bilious  form,  300. 

choleraic  form,  302. 

chronic  form,  303. 

fulminating  form,  300. 

gangrenous  form,  301 . 

hremorrhagic  form,  303. 

light  form,  300. 


INDEX 


1059 


li:i('illary       dy.sontory,      olinioal 
forms  of,   louff-contiiiuod  or 
rel;\[)siug,  303. 
typhoidal  form,  'M)'l. 
ulcerative  form,  301. 
(liaKiiOrfis  of,  31 1-323. 
differential  of,  314. 
epidemiology  of,  335-342. 
etiology  of,  343. 

determining  causes  in,  345. 
carriers  in,  347. 
direct  contagion  in,  34G. 
hands  in,  67. 

indirect  contagion  in,  349. 
mode  of  entrance  in,  345. 
modes  of  propagation  in, 
350,351. 
J)y  carriers,  354. 
by  flies,  354. 
in  clothing,  354. 
in  drinking  water,  345. 
in  dust,  353. 
in  food,  354. 
in  milk,  355. 
in  soil,  353. 
seat  of  infection  in  body  in, 

34.S. 
vitality  of  bacilli,  350. 
in  cold,  351,  352. 
in  darkness,  351. 
in  sunlight,  351. 
in  water,  350. 
j)rcdisposing  causes  in,  343. 
age  in,  343. 

domestic  animals  in,  344. 
exposure  in,  343. 
fatigue  in,  344. 
previous  infection  and,  344. 
racial  susceptibility  in,  344. 
spread  of  epidemics  in,  357. 
in  .Japan,  358. 
inununising  power  of,   344,  361. 
in  armies,  337. 
l)rophylaxis  of,  369.     {Stc  also 

Dysentery, 
serotherapy  in, 375-376. 
specific  treatment  of,  325-326. 
symptoms  of,  298. 

acute  dysenteric  ijeriod  in,  299. 
period  of  incubation  in,  29S. 
period  of  onset  in,  298. 
terminal  period  in,  299. 
symptomsofcomplicationsof,304. 
treatment  of,  324. 
Bacilli,  of  typhoid  affections,  inter- 
mediate, 117. 
tal>le     of     differences     between, 
114-115. 


Bacilluria  of  typhoid  fever,  192. 
Bacillus,  Ducrej''s,  559. 
Loefflcr's,  572. 

of  dysentery,  culture  and  isola- 
tion of,  41-43,  321-323.     •  • 
vitalitv  of,  in  various  media, 
350-354. 
Bacillus    carriers,     187,     199,    two 
groups  of,  189  et  se?.       {See 
also  carriers.) 
Bacillus  coli,  114,  115. 
Bacillus  cnteritidis,  93,  257. 
fcRcalis  alhaligeties,  117. 
proteus  I  uljaris  in  typhoid  fever, 

18. 
Pf/ocijaneus  in  typhoid  fever,  IS. 
Bacterial  therapy  of  typhoid,  149. 
Bacteriological       diagnosis,       first 
measure    in     an    epidemic, 
231. 
of  dysentery,  315-316. 

examination     for    cholera   vi- 
brios, 447. 
in  therapy  of  typhoid,  149  et  seq. 
Bacteriuria  in  typhoid,   110. 
Balanitis,  557. 

erosive  and  ulcerous,  564. 
Balantidium  coli,  367. 

dysenterj^  due  to,  309. 
Balkan  War,  cholera  in,  411. 

vaccination  against,  in  Greek 
Army,  450. 
typhus  in,  477. 
Balneotherapy,  134. 
Balzer,  503,  612,  619,  697,  702. 
Bar,  529. 

Barracks,  the  best  position  for,  227. 
Barrage,  treatment  by  attack  and, 

641. 
Basal  infiltration,  562. 

meningitis,  586. 
Base  zone  and  contamination,  515, 

516. 
Baths,  sulphur,  in  syphilis,  645. 
treatment  of  typhoid  fever  by, 

value  of,  21,  134  et  seq. 
warm,  in  treatment  of  tetanus, 
888. 
Bazin    and    Legendre's    syphilitic 
phifiues,  576,  577. 
Bechamp,  612. 
Bedsores,  treatment  of,  147. 
Behring  and  Kitasato,  demonstra- 
tion of  antitoxic  powers  of 
anti-tetanic  serum,  852. 
Belgium,  tetanus  in,  829. 
Belladonna  in  tetanus,  889. 
Bell-t;lappcr  penis,  542. 


K'tGO 


INDEX 


Beiiario,  G33. 

Beiizo  -  sulphono  -  para  -  aniino- 

phenvl    arsenate  of  sodium, 

612,  636. 
Benzoate  of  mercury,  solution  of, 

606. 
Bergeron  and  LetuUe,  524. 
Bertarelli's  method  of  examination, 

.554. 
Bertillon's  statistics  on  occurrence 

of  typhoid  fever  as  to  age 

and  sex,  170. 
Besredka  anti-anaphylaetic  treat- 
ment, 864. 
Betain  hypochlorate  in  anti-toxic 

treatment  of  tetanus,  884. 
Bevel,  the,  6-53. 

Beverages  capable  of  causing  con- 
tagion, 216,  238,  258. 
Biett's  collar,  573. 
Bile,  culture  from,  110. 
Bilgewater,  transmission  of  cholera 

vit)rio  bv,  435. 
Bilhiirzla,  309,313,368. 
dysentery  due  to,  309. 
Bilharziasis.  30N 

Biliary  retention  in  syphilis,  587. 
Bilious  form  of  bacillary  dysentery, 

300. 
luemoglobinuric    fever,  early,  in 

second     phase    of    primary 
paludism  in  malaria,  989. 
in  secondary  paludism  in  ma- 
laria, 1011. 

attack  of,  1013. 

blood  in,  1014. 

course  of,  1014,  1015. 

icterus  in,  1013. 

occurrence  of,  1013. 

urine  in,  1014. 
typhoid,  9. 
Biiiiodide     of     merr-ury,     aqueous 

solution  of,  606,  009. 
oily  solution  of,  606. 
Birth  rate,  influence  of  syphilis  on, 

527. 
liismuth,  suij-nitrate  of, 643. 
Jiizard,  505. 

Bladder    disturbances    in    paraty- 
phoid fever,  89. 
in.typhoifl  fever,  70. 
Blaschko,  525. 
JJleoding  in  treatment  of  t\'phoid 

fever,  141. 
Blood  oxanjination  in  malaria,  1018. 
ha,-matologicul  signs  in,  1033 
Jiiematozoa  in   chart  of,  1032, 
diagnostic  signs  of,   1025. 


Blood     examination    in    malaria, 
method  of  making  blood  film 
in,  1018. 
methods  o<"  staining  in,  1019. 
Laveran's  panchrome  in,  1024, 

1033.^ 
Senevet's     borax  -  rosin  -  blue 

stain  in,  1021. 
Tribondeau's  bi-eosinate  stain 

in, 1019-1021. 
water     used    in,    precautions 
regarding,  1022. 
Laugeron's  method  of  test- 
ing in,  1022. 
results  with  ordinary  water 

in.  1023. 
with  deep  staining,  1024. 
with  fahit  staining,  1023. 
with  intermediate  staining, 
1024. 
obtaining  blood  for,  1018. 

thick  drop  methodof,  1033. 
of  Plasmodium  falciparum,  1029. 
gametes  of,  1030. 
schizont  of,  1029. 
of  Plasmodium  malarioe,  1031. 
ama>boid  bodies  of,  1031. 
gametocytes  of,  1033. 
rosette  bodies  of,  1031. 
schizonts  of,  1031. 
of  Plasmodium  vivax,  1025. 
amoeboid  body  of,  1027. 
blood  corpuscles  in,  1025. 
gametes  (or  gametocytes)   of, 

1027. 
parasite  itself  in,  1025. 
schizont  of,  1025. 
preservation  of  slides  in,  1019. 
Blood    film,    method    of    making, 

1018. 
Blood  in  typhus,  489. 
typhoid  bacilli  in,  176. 
tvphoid  fever  and,  45  d  neq. 
Blood-culture,  48,  111,  231. 
Blue  cholera,  388. 
Blumenthal's  statistics  of  Wasser- 

mann  reaction,  554,  555. 
Boer  AVar,  dysentery  in^  341. 

typhoid  fever  in,  162. 
Boils,    frequency    of,    in    typhoid 

fever,  125. 
Boinet    and    Monges,    case   of   te- 
tanus of  left  upper  extrem- 
ity, 745. 
Bond,  case  of  cephalic  tetanus,  781 
Bones,  lesions  of  muscles  and,  648. 
Bordet,  554. 


INDEX 


lOGl 


Borol  method  of  avoidins;  false 
ophtlialtnopk'siii  in  exaini- 
imtioii  of  cephalic  tetanus 
complication  by  ophthalmo- 
plegia,737. 

Borne,  099. 

Bosnian  expedition,  dysentery  in, 
340. 
typhoid  fever  mortality,  IGl. 

Bottu's  mixtm-e  in  antitoxic  treat- 
ment of  tetanus,  SSfi. 

Bouquet,  Henri,  ca.se  of  late-ap- 
pearing cephalic  tetanus, 
770. 

Brand's  method  of  balneotherapy, 
134. 

Brisac,  M.,  692. 

Broca  Hospital,  690,  695. 

Brocq, 519, 527,  594, 612, 690. 

Brocq's  mother  plague,  576. 

Bronchial  fistula  in  hepatic  dysen- 
tery, 361. 

Bronchitis,  bacilli  in,  183. 

frequent  in  typhoid  feyer,  39. 
with    pleuropulmonary    conges- 
tion in  malaria,  986. 

Broncho-pneumonia     in     cholera, 
393. 
in  typhoid,  39. 

Broncho-pulmonary  complications 
in  typhus  exanthematicus, 
464. 

Broncho-typhoid, 9. 

Brouardil,  susceptibility  of  army 
to  typhoid  feyer,  172. 

Briinner,  Vaillard  and  Vincent,  in- 
fections theory  of  cephalic 
tetanus  with  ophthalmo- 
plegia, 735. 

liuccal    exanthem   in   paratviihoid 
fever,  83. 
mucous    membrane,    lesions    of, 

582. 
spirillae,  list  of,  553. 

Bucco-pharyngeal     diphtheria     in 
typhus  exanthematicus,  465. 
ulcerations     in     typhoid     fever, 
27-29. 

Budapest,  epidemic  of  cholera  at, 
414. 

Buisson,  case  of  cephalic  tetanus. 
781. 

Bullous  .syphilides,  579. 

Burns  and  ulceration,  cigarette, 
563. 

Cacao  butter,  GOO. 


Cachets.  594,  .595. 
mercurial,  597. 
proto-iodide  of  mercury,  591. 
Renault's  formula,  597,  598. 
Cachexia   in   second   i)hase   of   pri- 
mar\-   paludisin   in   malaria. 
993." 
anaMuia  in,  9S3. 
digestive  disturbances  in,  9S4. 
l)i'Ogiiosis  in,  9cS5. 
C^ilcium    chloride,    in    antitetani(; 
serotherapy,  8()4. 
in    local    treatment    of    wounds 
against  tetanus,  849. 
Calcium    hypochorite    tablets     for 
sterilisation    of    drinking    water, 
237. 
Calcimn  peroxide,    distinction    of 

tetanus  peroxide  by,  848. 
Calcium    sulphate,    action    of,    in 

body, 895. 
Calomel,  in  dysentery,  .329. 
in  syphilis,  546,  643,  645. 
intravenous  injections  of,  603. 
oil,  intramuscular  injections  of, 

604. 
ointment,  689. 
unsuitability  of,  546. 
Camps,  general  hygiene  in,  regard- 
ing dysentery,  373. 
regarding  typhoid,  227. 
location  of,  373. 

prophylaxis  of,  against   typhoid 
fever,    227,    246.        (C/.     also 
Army,  the.) 
typhoid  injection  in,  207. 
Carbolic  acid,  concentrated  in  sy- 
philis, 546. 
in    antitoxic    treatment    of    te- 
tanus, 880. 
mode  of  action  of,  882. 
results  in,  881. 
Carbolic  gargles  in  syphilis,  644. 
Cardiac,  cases  and  vaccination,  275. 
complications  in  typhoid  fever, 

146. 
diseases,  typhoid  fever  and,  19. 
disorders  in  paratyphoid  fevers, 
84. 
in  syphilis,  635. 
Cardio-vascular  syndromes  in  sec- 
ond phase  of  primary  palu- 
dism  in  malaria,  987. 
erythromelalgia  in,  988. 
Raynaud's  disease  in,  987. 
symmetrical  gangrene  in,  987. 
visceral  circulation  in,  disorders 
of,  988. 


10G2 


INDEX 


Garduoci's  method  of  administra- 
tion   of   (luiuine    in   the    in- 
tei-vals    in    seconchiry    palu- 
(lism  of  malaria,  lOol. 
Carle,  .")(n),  510,  5(),S. 

htati.sties    of,    in    syphilis,    509, 
510,512,514,515. 
CariKjt,  case  of  late-appearing  te- 
tanus of  left  upper  extrem- 
ity, 7()5. 
Cari)liol()}fy,  60. 
Carriers,  of  cholera,  419-425. 
healthy,  421. 
r)f  cbsenterv,  ;-547-348,  354,  3G1- 

362,872,374. 
of  paratyphoid  bacillus,  25G. 
oi  typhoid,  186,  246,  256. 
classification  of,  189. 
biliary  or  faecal,  189. 
chronic,  189. 
urinary,  182. 
exposure  to  contagion  by,  196. 
history    of    epidemics    caused 

by, 193. 
latent,  234. 
jjrecautions  against,  195,  234, 

235. 
transmission  of  typhoid  con- 
tagion by, directly,  199-200. 
indirectly,  201. 
sj^philitic,  523. 
isolation  of,  670. 
Castellani,      vaccination      against 
cholera,  450. 
against  bacillary  dysentery,  375. 
Catarrhal  jaundice,  66. 
Cathocus    form    of    tetanus  (Sau- 

vages),  780. 
Cauterisation  in  syphilis,  644. 
Cawadias,       vaccination      against 

cholera,  450. 
Central     pharmacy    for     Military 

Hospitals  tabloids,  597. 
Centres,     dermato-syphilographic, 
676,677. 
for  treating  civilians  for  syphilis, 

690. 
medical  inspection  in,  673. 
venereological,  676,  677. 
Cephalic  tetaims,  707,  709. 

case    of     late-appearing,    Henri 

Bouquet,  770. 
non-paralytic,  709. 
summary  of,  914. 
paralytic,  summary  of,  915. 
varieties  of,  707-708. 


Cephalic  tetanus  with  facial  paralv- 
.sis,  712. 
age  and  sex  in  occurrence  of,  715. 
antitetanic    injection    of  wound 

in,  728. 
bacteriology  of,  726. 
characteristics  of,  712. 
clinical  picture  in,  715. 
diagnosis  of,  727. 

from  tic  douloureux,  727. 
from  traumatic  spasms.   727- 

728. 
in  infections  wounds  of  face. 

728. 
in  unilateral  symptoms,  727, 
duration  of,  726. 

etiology  and  frequency  of,  714. 
facial  paralysis  in,  721. 
clinical  characters  in,  721. 
in  complete  peripheral  facial 

paralysis,  722. 
in  lower  facial  type,  722. 
in  superior  facial  type,  723. 
in  total  facial  paralysis,  723. 
commencement  of,  721. 
development  of,  724. 
diagnosis  of,  724. 
pathogenesis  of,  725. 
prognosis  in,  724. 
situation  of,  721. 
fever  in,  725. 
history  of,  713. 
incubation  in,  718. 
individual  signs  in,  717. 
muscular  contractions  in,  719. 
degree  of,  719. 
extension  of,  720. 
in  paralysed  muscles,  719. 
in  side  not  paralysed,  720. 
prognosis  of,  726. 
situation  of  wound  in,  717. 
trismus  in,  718. 
Cephalic  tetanus  with  ophthalmo- 
■        plegia,  279,  731. 
clinical    manifestations  of,  731. 
initial  symptoms^  in,  731. 
pupillary     disorders    in,    734. 
situation  of    ophthalmoplegia 

in,  734. 
symptoms  of  ophthalmoplegia 
in,  731. 
diagnosis  of,  737. 

false  ophthalmoplegia  in,  737. 

constancy  of  spasms  in,  738. 

hystero-traumatism    in,     740. 

in  lesions  of  meningeal  origin, 

738. 


INDEX 


1063 


Cephalic  tetanus  with  ophthal- 
moplegia, diaRuosi'^  of,  in 
lesions  of  nieninjiea!  origin, 
cerebro-spinal  meningitis  in, 

73S. 
tubercular     meningitis     in, 
738. 
in  traumatic  lesions,  739. 

fracture  of  orbit   and    l)ase 
of  skull  in,  739. 
etiologj'  of,  730. 

occupation,  age,  sex  in,  730. 
seat  of  infection  in,  730. 
history  of,  729. 
pathogenesis  of,  735. 
theories  of,  735-736. 
through    medium    of      motor 

nerves  of  the  face,  73(1 
through  medium  of  trigeminal 
nerve,  736. 
prognosis  of,  741. 
summary  of,  916. 
Cephalic  tetanus  without  paralysis, 
dysphagic,  710. 
hydrophobic,  711. 
pare,  710. 
simple,  710. 
Cephalic  tetanus  with  paralysis  of 
the    hypoglossal  nerve,   742.  • 
course  of.  742. 

sign;^  and  symptoms  of.  742. 
facial  paralysis  in,  743. 
ophthalmoplegia  in,  743. 
trisnuis  and  dysphagia  in,  742. 
summary  of,  916. 
Ceical  decoctions  in  tvphoid  fever, 

129. 
Cerebral  form  of  pernicious  attacks 
in  second  phase  of  primary 
paludi.sm  in  malaria,  999. 
apoplectic,     isolation     tvpe     of, 

999. 
convulsive    meningeal    tvpe    of. 
1000. 
Cerebro-meningeal     symptoms    in 

•    syphilis.  5S5. 
Cerebro-spinal     lymphocytosis     in 

.syphilis,  oSO,  5S6. 
Cerebro-spinal    meningitis,    differ- 
entiated    from     paraplegic 
form  of  local  tetanus,    809. 
from  typhus,  469. 
paralytic  manifestations  of.  73S. 
Chalons,  dysentery  at,  353,  373. 
Chancre,  in  typhoid.  20. 
(Jhancre,  syphilitic,  536. 

characteristics    of,    537,    538, 
545. 


Chancre,      syphilitic,     commence- 
ment of,  538. 
diagnosis  of,  545. 

complement   ftxation   test     in, 
554. 

evolution  of  chancre  and.  547. 

laboratory  aid  in,  .549. 

oljjcctive  signs  in,  545. 

parasite    in,    examination   for, 
549. 

patient's  antecedents   in,  547. 

secondary  symptoms  in,  547. 

Wasscrmann  reaction  in,  554. 
diagnostic  elements  of,  545. 
diagnostic  importance  of.  545. 
differential  diagnosis  of.  557. 

from      common      excoriations 
of  genital  organs,  562. 

from  ecthyma,  561. 

from  epithelioma,  564. 

from     erosive      and      ulcerous 
balanitis,  564. 

from      gangrene      of      genital 
organs,    562. 

from  genital  herpes,  557. 

from  pseudo-chancre,  566. 

from  mucous  plaques,   564. 

from  scabies,  561. 

from  simple  chancre,  558. 

from  tertiary  ulcerations,  565". 

from  ulcerations  induced  with 
object  of  simulation,  5()3. 
dwarf,  540. 
effect  of.  544. 
evolution  of,  543. 
extragenital,  568. 
giant,  540. 
in  children,  522. 
in  rosette,  539. 
incubation   period    of,   536,   537 

560. 
indurated,  540. 
infective,  564. 
infiltration  and  tumefaction   of, 

.542.. 
inoculation  of,  542. 
localisation  of,  syphilitic,  537. 
mixed,  561. 
multiple,  542.  559. 
novar.senobenzol    and,  619. 
of  beard,  etc.,  568. 
of  lip.  568,  569,  643,  644. 
of  tonsil,  57.0,  571,  644. 
of  urethra,  643. 
])rostitutes  and,  695. 
recurrent,  567. 
results  of  inoculation,  542, 
scal)ous,  539. 


10G4 


INDEX 


Chancre,    sypliilitio,     simple,  557, 
55S,  550,  560. 
inoculation  of,  559. 
siuKle,  542. 

sta}j;e  of  maturity  of,  538. 
treatment  of,  <i42,  648. 
unsuitable    remedies    applied 
to,  .545,  546. 
Chancrous  induration,  562. 
Chancriform  sulphides,  565. 
Chant emesse's  ophthalmo-reaction 
in  typhoid,  105. 
serum  therapy,  148. 
Cheeks,  mucous  membrane  of,  le- 
sions in  secondarv   syphilis, 
583. 
Childhood,  typhoid  fever  in,  14. 
Children  contaminated  bv  syphilis, 
522. 
mortality   of,    in    typhoid   fever, 

180. 
susceptibility     of,     to     typhoid 
fever,  180; 
Chills,  avoidance  of,  360. 
CMiilodon  dentatus,  367-36H. 
Chinese  ink  method,  551. 
Chino-.Japaneso     War,     dysentery, 

in,  340. 
Chloral  in  tetanus,  889. 

administration    of,     by    mouth, 
800. 
by  rectum,  803. 
poisoning  by,  phenomena  of,  SOI 
eruptions  in,  892. 
disorders  of  nutrition  in,  802. 
nervous  disorders  in,  893. 
results  of,  889. 
Chlorate  of  potash  solution,  667. 
Chloriiie  for  sterilisation  of  drink- 
ing water,  237. 
Chlorodyne  in  treatment   of  chol- 
era, 404-405. 
Cholecystitis  in  typhoid,  67. 
Cholera,  antimonial,  398. 
Cholera,  Asiatic,  353,  370. 
accidents,  complicating,  392. 
chronic  diarrhoea,  302. 
gangrene,  392. 
cutaneous,  392. 
of  extremities,  392. 
visceral,  392. 
jaundice,  393. 
nervous  accidents,  393. 
pulmonary  complications,  303. 
broncho-pneumonia,  303. 
pneumonia,  303. 
secondarv  infections,  394. 
algidity  of,  383-384,  387-389. 


Cholera,   Asiatic,  clinical  forms  of, 
304,  305-306. 
according  to  evolution  of  dis- 
ease, 394. 
cholera,  395. 
choleraic  diarrlura,  394. 
cholerine,  395. 
according  to  epidemics,  397. 
as  affectted  bv  age  of  patient, 

395. 
as    affected     by    pathological 

condition,  396. 
as  affecting  physical  conditions 
of  woman,  306. 
lactation,  30(j. 
menstruation,  306. 
pregnancy,  30(). 
complications  of,  302-394. 
cramps  in.  383. 
diagnosis  of,  308-403. 

as  to  causative  agent,  399. 
bacteriological  e.xamination  in, 

400. 
identification  of  vil)rio  in,  402. 
l)y  agglutination  text,  403. 
by    appearance    ol    cultures 

on  gelatine,  402. 
l)y  inoculation,  403. 
by    microscopical    examina- 

"  tion,  402. 
])y     nitrous-indol     reaction 
test,  402. 
search  and  isolation  of  vibrio 
in,  400. 
differential  diagnosis  of,  .308. 
from  chemical  poisoning,  308. 
from  food  poisoning,  390. 
from  poisonous  fungi,  308. 
from   pernicious   algid    access, 
307. 
e|)idemiology  of,  409-412. 
etiology  of,  413. 

determining  causes  in;  cholera 
vibrio,  41(). 

invasion  of,  in  body, 41 6. 
transmission  of,   by  choler- 
ine patients,  418. 
by  feces  and  vomit,  416. 
by  healthy  carriers,  419. 
by     recovered     patients, 

419. 
rapidity  of,  417. 
favoring  factors  in,  413. 
age  and  race,  413. 
alcoholism,  413. 
hot  weather,  414. 
modes  of  propagation  of  chol- 
era vibrios  in,  420. 


INDEX 


1065 


Cholera.  Asiatic,  etiology  of,  modes 
of  propagation  of  cholera 
vibrios  in.  by  direct  trans- 
mission, 426. 

survival  of  vibrio  in  de- 
jecta in,  427. 
survival  of  vilirio  in  other 
media.  427. 

effect  of  moisture  on  1 428 
by  indirect  agents,  428. 
by  clothinK,  430. 
l)y  bilgewater.  435. 
by  corpses,  430. 
by     drinking     water     on 

ships,  436. 
bv  earthworms,  43o. 
by  fish.  435. 
bv  footwear,  435. 
by  milk,  436. 
by  oysters,  435. 
by  water,  431. 

contamination  of,  434. 
effect    of    sunlight    on, 

431. 
for  drinking,  433. 
marine  salt  in,  434. 
mud    of    rivers,    wells, 

etc.,  in.  432-433. 
sources    of    contamina- 
tion of,  432. 
Cholera,    Asiatic,    evacuation    of, 
381-382. 
Foudrovant  form  of,  305. 
history  of,  409. 
in  typhoid  fever,  18. 
lactation  in,  396. 
menstruation  and,  396. 
])regnancy  in,  396. 
prophvlaxis  of,  438-453. 
against  vil^rio,  439. 

bacteriological  examination 
in,  440. 

cultivation  and  examina- 
tion of,  441. 
identification  of.  441. 
sanitary  regulations  regard- 
ing, 442. 
immediate   procedure   in,  first 
cases  in,  442. 
care  of  patient.  443. 
compulsorv   notification  in, 

445. 
disinfection  in.  444. 
regarding  ships  and  travel- 
ers, 444. 
saline  purgatives  in.  446. 
supervision  in,  443. 
on  Ijoard  warships,  438. 


Cholera.    Asiatic,  prophylaxis    of, 
regarding  contagion,  446. 
regarding  fa vorins  causes,  438. 
vaccination  in, 448. 
reaction  after.  389-392. 
relapses  of,  394. 
symptoaiatologv  of.  379-397. 
cholera  syndrome  in.  379. 
clinical  manifestations  in.  379. 
choleraic  period  in.  380. 
algid  phase  in.  383. 

disorders  of  at)sorptiou 

in,  386. 
disorders  of  circulation 

in.  384. 
disorders  of  respiration 
and     phonation     in, 
385. 
disorders    of    secretion 

in, 386. 
disorders     of     temper- 
ature in,  383. 
external  appearance^ 
of  patient  in.  387. 
phase  of  evacuation  in, 
380. 

cramns  in.  383. 
diarrhcea  in,  380. 
vomitine  in,  383. 
initial  period  or  period  of 
invasion  in.  380. 
diarrhrea  in,  380. 
period  of  incubation  in.  379. 
period  of  reaction  in,  38-J. 
abortive  reaction.  390. 
regular  reaction.  389. 
typhoid  state,  391. 
treatment  of.  40  i. 

exi^ectant  symptomatic,  404. 
for  algidity.  406. 
for  asphyxia,  406. 
for  cramps.  405. 
for    premonitory    diarrhcea, 

404. 
for  vomiting,  405. 
of  Manson,  404. 
rational,     bv     restoration     of 
liquid  lost.  406. 
enterochysis  in.  406. 
hyperdermochvsis  in,  406. 
veno\is  transfusion  in,  407. 
vomitins:  in,  382. 
women,  affected  bv.  396. 
Cholera,  arsenical,  398. 
blue,  38S. 
cvanotic,  388. 
dry.  381. 
nostas,  94. 


1066 


INDEX 


Cholera,  pallid,  388. 
stibial,  398. 

vibrio,  379,  399-403,  413-437. 
Choleraic  diarrhoea,  394-395. 

dysentery,  300. 
Choleriforni      attacks     in      second 
phase  of  primary  paludism, 
979. 
Cholerine,  395. 

cholera  infection  from,  418. 
Cholesteiin  in  antitoxic  treatment 

of  tetanus,  884. 
Choroiditis,  587. 

Chronic  scrofulous  ulcerations,  531. 
Cicatricif*!  tetanus,  7S6. 
Cigarette  l)urnsand  ulceration, 563. 
Circulation,   the,  in  cholera,    384- 

385. 
Circulatory  system,  the,  in  typhoid 

fever,  4 1  et  t-eq. 
Circulars  on  precautionary  meas- 
ures in  syphilis,    670,    672. 
673,679,(680,681,692. 
Cirrhosis,  acute,  635. 
Civatte,  527. 

Civil  War,  typhoid  fever  in,  160. 
Civilians  and  syphilis,  518,  520. 

centres  for  treatinjr,  690. 
Clandestine  prostitutes  and  public 
register,  702. 
and  treatment,  694. 
Claude    and    Lhermitte,    cases    of 
attenuated     form     of    local 
tetanus  with  slow  develop- 
ment   and    prolonged    incu- 
bation, 817. 
Climate  and  typhoid  fever,  166. 
Clinic,  Tarnier,  529,  530. 

table  of  confinements  in,  530. 
Clothing  in  syphilis  infection,  667. 
transmission    of    cholera    vibrio 
by,  430,  435. 
of  dysentery  by,  354. 
typhoid  infection  from,  205. 
Cocadylate   of  soda   with   quinine 

in  treatment  of  malaria,  1052. 
Cocca-bacillary  dysentery,  309. 
Cochin  hospital,  685. 
Codex  formula,  603. 
Cold,    an    aid    to    develoi)inent    of 
tetanus,  832. 
prevention  against,  in  treatment 

of  tetanus.  845. 
vitality  of  dysentery  bacilli   in, 
351,352. 
Cold  air  refrigeration,  139. 

and  wet,  predisposing  to  tetanus, 
921. 


Cold-water  compresses,  138. 
Colitis,  mercurial,  663,  664. 
Collargoi,  143. 

Colles  and  Follin,  cases  of  tetanus 
with  traumatic  spasms,  727. 
Colloidal  metals  in  antitoxic  treat- 
ment of  tetanus,  883. 
Comma  bacillus,  379. 
Complement,  fixation   of,  in  syph- 
ilis, 554. 
in    test    for    typhoid    affections, 
121. 
Compressed    tabloids    in    syi)hilis, 

597. 
Compresses  in  t\'phoid,  138. 
Compromise  of  race,  523. 
Compulsory   antitvphoid   vaccina- 
tion, 242,  286. 
Compulsory  notification  in  cholera, 
445. 
in  dysentery,  370,  372. 
of    typhoid    and    paratvphoid 
fevers,  233,  262. 
Confinements    in    Tarnier    Clinic, 

530. 
Condyloma  latum,  582. 
Congenital  syphilis,  retarded,  531. 
Constantinople       conference       on 

cholera,  379. 
Constipation  in  typhoid,  144. 
Consultations  in  syphilis,  690. 
Contagion   in   amoebic   dvsentery, 
360-361. 
in  cholera,  417-437. 
in  dysentery,  345-349. 

indirect,  349-357. 
in   svphilis,   in   army,   origin   of, 
^509. 
isolation  in,  675. 
nuinition  works  and,  517. 
in  treatment  of  tetanus,  851. 
in  typhoid,  by  food,  257. 
direct,  198  et  tseq. 
due  to  meat,  258. 
factors  of,  179  et  seq. 
in  the  trenches,  250. 
indirect,  201. 

by  patients  or  carriers,  204 
et  seq. 
Vincent's  dictum  on,  199. 
Contagious    diseases,    notification 

of,  234. 
Contamination    in    sj'philis,    army 
zone,  514,  515,  698. 
in  bgse  zone,  6i)9. 
in  depots  and,  516. 
in  rest  zone,  698. 
o[  children,  522. 


INDEX 


1067 


Contamination,  in  syphilis,  of  wo- 
men by  thoir  luishandri,  521. 
statistics    showing   so  uro   of, 
512. 
non-vonoroal,  507,  509. 
statistics  of  venereal,  507,  50S. 
typlioid,  2()1. 
Continued    treatment    in    syphilis, 

()42,()49,  ()50,  651. 
Convalescence  after  typhoid  fever, 
21. 
complications  of,  43. 
proi)hylaxis  in,  235. 
psychical  disturbances  in,  02. 
Convulsions  in  malaria,  992. 
Convulsive  meninjiieal  type  of  per- 
nicious    attack     in     second 
phase  of  primary  paludism 
in  malaria,  1001. 
Corpses  as  .source  of  infection  in 
typhoid  fever,  1S4. 
transmis.sion    of    cholera    vibrio 
by,  430. 
Corpuscles,  the,  changes  in,  45. 
Country  contamination  in  typhoid, 

20G. 
Courtellemont,    case  of   local   tet- 
anus of  IcL',  740,  782. 
Court ois-Suffit  and  (liroux,  case  of 
tetanus    of    left    lower    ex- 
tremity, 774,  7SS. 
Crami)s  in  choleni,  383. 

treatment  of.  405. 
CrimeanWar,  dysentery  in, 340, 343. 

typhus  in,  470. 
Cri.ses,  nitritoid,  032,  035. 
t-ryogenine  in  typhoid  fever,  140. 
Cultivation  of  cholei'a  vibrio,    400. 
of  dysenter\-,  bacillus,  315-321. 
of  Entamoeba,  315-320. 
Cunnnerbimd,  ()07. 
Curare  in  tetanus,  889,  925. 
Cure,  Fournier's  intermittent,  598. 
Curtillet    and    I^ombard,    case    of 
local    tetanus  of   ui)per  ex- 
tremity, 745. 
Cutaneous    affections    in    syphilis, 
pruriginous.  584. 
statistics  of,  505,  500. 
ulcerative,  524. 
Cutaneous    eruptions     in    syphilis 
and  :u'seno-l)enzol,  035. 
lesions     of     secondary     syphilis, 
573,  020. 
Cyanide    of    mercury    in    syphilis, 
607,  008. 
albuminuria  and,  004. 
dose,  611. 


Cy 


1 
Cy 

( 
Cy 
C^y 
Cy 

Cy 


anide  of  mercury    in    syphilia, 

njections  of,  040,  042. 

ntraveimus  injections  of,  608. 

)recautions  after,  003,  004. 

anido  of  potassium  in  syphili.s, 

•.08. 

anogen,  60S. 

anotic  cholera.  388. 

cHtis,  587. 

sts  of  Entamoebae,  318-320. 


Danger,  instruction  as  to  venereal, 
682. 
.syphilis  as  a  national,  518. 
Dangers  of  insoluble  injections,  600. 
Danusz,  637. 
Darkness,     vitality    of    dysentery 

bacilli  in,  351. 
Deafness,  580,  0.33. 
Dean   and   Adamson,    vaccine   for 

dysentery,  376. 
Deaths,     from     arsenobenzol     and 

novarsenobenzol,  632. 
Defaced  paludism,  961. 
Defervescence  in  typhoid,  55. 
Delayed  roseola,  recurrent  or,  574, 

575. 
Delirium  in  malaria,  992, 

in  typhoid,  60. 
Demontmerot,   case  of  paraplegic 

form  of  tetanus,  781. 
Dengue,  Mediterranean,  953. 
Depots,  army,  treatment  of  syphilis 
in,  560. 
contamination  and,  516. 
Dermato  -  svphilographic    centres, 

676,  677. 
Diabetic     patients     and     typhoid 

fever,  18. 
Diarrhoea,  chronic.  311. 
in  cholera,  380,  394. 
chronic.  392. 
premonitory,  380. 
treatment  of,  404. 
in  second  phase  of  primary  at- 
tack in  malaria,  981. 
in  syphilis,  635,  651. 
in  typhoid,  26,  31,  144. 

cachectic,  23. 
trench,  308,  311,  369. 
Diazo-reaction  in  typhoid,  71,  84. 
Dichlorhydrate      of      dioxydiami- 

novarsenobenzol,  612. 
Dicrotism  in  typhoid,  51. 
Diet  in  dysentery,  324. 

of  typhoid  patients,  128  et  seq. 
Difficulties    of    intravenous    injec- 
tion, 661. 


1068 


INDEX 


Digestive    symptoms    in    typhoid, 

27. 
Dioxj-diamido  -  arsenobenzolmono- 
methylene    sulphoxylate    of 
sodium,  615. 
Diphtheria  in  typhoid  fever,  17. 
"Disciplined"    febrile    attacks    in 
secondary  paludism  in  ma- 
laria, 1005. 
Disease,  Landry's,  633. 

discussions  on  venereal,  678. 
lectures   on   venereal,    680,   683, 

684,  685,686.^ 
war  and  venereal,  503. 
Diseases  simulating  typhoid  fever, 
105,232. 
with  which  mucous  plaques  may 
be  confused,  583. 
Disinfection  in  cholera,  442. 
in  dvsenterv.  372-376. 
in  tvphoid,  233,  243. 
in  typhus.  498-503. 
Dispensaries,  685. 
Distilled  water  and  novarsenoben- 
zol,  616.  617,  618. 
and  syphilis,  654. 
Disturbances,  cardiac,  635. 
Diuretics,  143. 
Domestic    animals,    dysentery    in, 

344. 
Donovan's  solution,  61^. 
Dose  of  novar.senobenzol,  625,  626, 
627,  628. 
of  proto-iodido  of  mercury,  596. 
Dressings,  water,  643. 
Drinking  water  as  source  of  dysen- 
tery infection,  355,  365. 
carrier  of  paratvphoid  infection, 

258. 
carrier  of  typhoid  infection,  210. 
necessitv  of  bacteriological  con- 
trol of,  249. 
in  typhoid,  236,  258. 
on  shif)S,  transmission  of  cholera 

vibrio  by,  436. 
sterilisation  of.  237,  247. 
Drinks  in  .syphilis,  667. 
Droijsy,  588. 
Drugs,  antipyretic,  140. 
care  in  giving,  648. 
danger  of,  in  typhoid  fever,  140. 
for   conibating   infection    in    ty- 
phoid, 143. 
Dry  cholera,  381. 
Ducrey's  Ijacillus,  559. 
Duguet's  ulcers,  6,  28,  82,  183. 
Dumoutliiers,  619. 


Dupre,  Schoeffer  and  -Le  Fur  case, 
of  tetanus  with  persistence 
of  spasms,  798. 
Dupuytren's  pills,  596. 
Dust  as  source  of  dysentery  infec- 
tion, 354. 
Dutch  East  Indies,  cholera  in,  410. 
Dwarf  chancre,  540. 
Dysenteric  bacilli,  differential  char- 
acteristics of,  322. 
Dvsenteries  due  to  various  etiolog- 
ical   agents,    308-310,    333, 
367-368. 
Dysenteriform  symptoms  in  second 
phase  of  primary  paludism 
in  malaria,  982. 
Dysenteriform  enteritis  in  malaria, 

treatment  of,  1047. 
Dysentery,  amoeba  of,  316. 
associated  with  malaria,  1016. 
clinical  forms  of,  300-304. 
complications  of,  304. 
definition  of,  395. 
diagnosis  of,  311-323. 

of  dysenteric  syndrome,  311. 
chronic  diarrhoea  and,  3l2. 
stools  in,  311. 
diagnosis  of  nature  of,  313. 

bacteriological     diagnosis    in, 
321. 

culture  in,  321. 
identification  in,  321. 
clinical  examination  in,  313. 
laboratory  research  in,  315. 
microscopic    examination    in, 
315. 

ot  amoeba  of  dysentery,  315. 
cysts  of,  39. 

of  fsecal  discharges  ,  315. 
sero-diagnosis  in,  313. 
differential  diagnosis  of,  313. 
due  to  Balantidium  coli,  309. 
due  to  Bilharzia,  309. 
epidemics  of,  336-342,  353,  357. 

in  .Japan,  358. 
epidemiology    of,    general    con- 
sideration of,  333. 
etiology  of,  343. 

of  bacillary  dysentery,  343. 
hepatic  abscesses  in,  361. 
in  armies,  337-342. 
malari.il,  311. 
mixed  forms  in,  328. 
prophylaxis  of,  369-376. 
symptomatology  of,  295. 
prophvlaxis  of,  369. 

avoidance  of  chills  in,  309. 


INDEX 


1069 


Dyson  t(M-y,    i)Vf)pliyl;ixis;    of,    l);ir- 

tonol()}i;ir:il  antilysis   in,  'MX. 
c'onipnlsorv      notifiratioa      in, 

370,  ;^72. 
disinfoction  in,  370,  372,  373. 
flies  and,  374. 
food  in,  309,  374. 
f?<Mioral  con^idtnation  of,  333. 
fKMioral  liyKit'Ke  in,  'i(S*d,  372- 

in  camps,  373. 
iiQvm  carrier.s  in,  372,  374. 
importance     of     prophylactic 

measures  in,  371. 
isolation  in,  370,  373. 
la))oratory     examination     in, 

370. 
location  of  camps  in,  373. 
medication  in,  375. 
serum  immunisation  in,  375. 
■vaccination  in,  375. 
spirillum,  30'.). 
symptomatology  of,  395. 

dysenteric  syndrome  in,   333, 
"395. 

abdominal  pain,  395. 

stools,  397. 

tenismus,  396. 
tieatment  of,  324-332. 

in  ama'hic  dysentery,  326. 
in  hacillary  dysentery,  324. 
in  chronic  dysentery,  330. 
in  mixed  dysentery  (hacillary 

and  ama>bic,t,  32S. 
in  negative  results,  328. 

calomel  in,  329. 

ipecacuanha  in,  328. 

opium  in,  329. 

saline  purgatiyes  in,  329. 
Dy.sentery,  amcrlVic,  chronic,  361. 
epidemiology  of,  359. 

contagion  in,  by  carriers,  361. 

innnediate,  362. 

indirect,  363. 
by  water,  364. 
encysted  ama'ba  in,   363. 
vitality  of  amo'ba  in,  364. 
gcograjjuical    distril)ution    in, 

365. 
of  mixed  infections,  366. 

amo'l>o-ba('illary,  366. 

with  other  parasites,  367. 
j)arasite  in,  359. 

animals  carriers  of.  360. 

localities  infected  by,  356. 

mode   of    entrance    of,    into 
body,  360. 

ipersistence  of,  361. 


Dysentery,    ama?bic,    parasite    in 
point  of  departure  of,  from 
body — excreta,  361. 
symptoms  of,  305. 

abdominal  pain  in,  305. 
diarrhoea  in,  305. 
in  chronic  form,  306. 
symptoms  of   complications    of, 
306. 
abscess  of  liver  in,  307. 
peritonitis  in,  307. 
Dysentery,  bacillarv,  clinical  forma 
of,  300. 
bilious  form,  .300. 
choleraic  form,  302. 
chronic  fonn,  303. 
fulminating  form,  .300. 
gangrenous  form,  301. 
ha^morrhagic  form,  303. 
light  form,  300. 
long-continued     or     relapsing 

form,  303. 
typhoidal  form,  302. 
ulcerative  form,  301. 
epidemiology  of,  335. 

in  armies  at  war,  337. 
etiology  of,  343. 

determining  causes  in,  345. 
carriers  in,  .341. 
direct  contagion  in,  346. 
hands  in,  347. 
indirect  contagion  in,  349. 
mode  of  entrance  in,  345- 
modes    of    propagation    in, 
350,  352. 
by  carriers,  354. 
by  flies,  354. 
by  clothing,  354' 
in  drinking  water,  355. 
in  dust,  353. 
in  food,  354. 
in  milk,  355. 
in  soil,  353. 
seat  of  infection  in  body  in, 

348. 
vitality  of  bacilli  in,  350. 
in  cold,  35 L,  352. 
in  darkness,  351. 
in  sunlight,  351. 
in  water,  351. 
predisposing  causes  of,  343. 
age  in,  .343. 

domestic  animals  in,  344. 
exposure  in,  343. 
fatigue  in,  343. 
previous  infection  and,  344. 
racial  susceptibility  in,  344. 
spread  of  epidemics  in,  357. 


1070 


INDEX 


Dysentory,   l)acillary,   iiiiinuiiisiiip; 
power   of.  'M-i,  o()l. 
symi.toiiis  of,  21)S. 

ac'ulodysoiitoric  ))oriod  in,  299. 
period  of  incuhatioii  in,  29S. 
l)eriod  of  onset  in,  29S. 
terminal  period  in,  299. 
svnii)tonis    of    coini'lieation.*:    of, 
■  304. 
Dysentery,  chronic,  330. 
Dyspliagic    form    of    cei)halic    te- 
tanus, 710. 
Ear,  and  typhoid  fever,  GO. 
Karlv    tetanus,    inculjatiou    peiiod 

of.  7S3. 
Eartlnvornis,  transmission  of  chol- 

erti  viV)rio  by,  435. 
Ecthyma,  539,  557,  5G1. 
Eczema,  20. 

Effectives,    diminution    of,    in    sy- 
philis, 523. 
Ehrlich.   592.   612,   613,   614,   615, 

()22,  625,  636,  637,  63S. 
E!ectrar«ol,  143. 
Embolism  in  syphilis,  663. 

of  ijulmonarv  artery  in  tvphoid, 
40. 
Enil)r\-ocardia,  41. 
Encephalitis,  acute,  632. 
Endermic    administration,    in    sv- 
philis,  600. 
mercurial  medication,  594. 
Endocarditis,  41. 

t\-phoid  foi'in  of  infective,  103. 
Endoneural   injections   in   tetanus, 

923. 
Enemata,  139. 
iMier^etic  treatment,  641. 
KiiUuiKL'lxi  cull,  319,  320. 
Enianwhd  di/sentcricte.'MH.  319.320. 
Ent'iNKvhd  liistolyticn,  318,  319. 

encysted,  363. 
EnUtnnehd  tetrrujcnd,  31 S. 
Enteric  fever  {Sec  Typhoid  fever). 
ICnterococcus  injections,  101. 
I'iphemeral  fever,  466. 
"Epidemic    bv    contact,"    in    tv- 

l)hoid,  iO'.). 
I'^pidemics    of    tvphoid,    254,    272, 
282,  2S7,  288. 
blood-examination  in,  243. 
characters  and  evolution  of,  220 

disinfection. in,  243. 
drinkinii  water  and,  236,  242. 
due;  to  oysters,  209,  239,  261. 
first  measures  in,  231 . 
treatment  of  e.xcivta  in,  244. 


Epidemiolofziy  of  typhoid  fever,  156 

ct  seq. 
F^l>ileptiform  attacks,  63. 
Epithelioma  in  .syi)hilis,  564. 

of  jjenis,  5.57. 
Erosive  and  ulcerous  balanitis,  561. 
Eruptions     and     arsenobenzol     in 
.syphilis,  520. 
cutaneous,  635. 
Eruptions  in  typhoid,  76. 

in  serotherapy  of  tetamis,  858. 
Eruptive    fevei-s,    special    sympto- 

matoloK.v  in,  99. 
Ery.sipelas  in  typhoid  fever,  18. 
Erythemata  in  typhoid,  78. 

medicamental,  in  syphilis,  575. 
Erj'thromelalsia    in    second    phase 
of  primarv  paludism  in  ma- 
laria, 9S7.' 
E.sau,  case  of  local  tetanus  of  hand, 

745,  781. 
Ether  iti  tetanus,  889. 

vaccine,  151. 
European  War,  dysentery  in,  341. 
ty]>hoid      in,      bacteriological 
analysis  of  beer  in,  238. 
lioUution  of  water  in,  215. 
rarity  of,  163. 

vaccination    adopted    by    all 
belligerents  for,  286 
typhus  in,  477. 
Examination    in    syphilis,    Berta- 
relli's  method  of,  554. 
Giemsa's  method  of,  550,  551. 
of  patients,  precautions  in,  540. 
Exanthemata,  acute,  typhoid  fever 

and,  17, 
Exanthematic    typhus.      (See    ty- 
phus exanthematicus.) 
Excoriations   of   genital   organs  in 

syphilis,  562. 
Exfoliative  erythrodermia,  general- 
ised, 635. 
glossitis,  marginate,  583. 
Exostosis,  531. 
Extra-geTiital  chancres,  570, 
Eye,  in  tyi)hoid  fever,  65. 
Eye  and  eyebrow  as  seat  of  infection 
in  ophthalmoplegic  tetanus, 
730. 
Eye  lotion,  647. 

Face,  infectious  wounds  of,  differ- 
entiated  from    cephalic    te- 
tanus with  facial  paralysis, 
728. 
treatment  of,  728. 


INDEX 


1071 


F:ic-c,  motor  iumvos  of,  orijiin  of 
infection  in  cephalic  tetanus 
\v  ith  o  '>  h  t  h  a  I  m  o  p  1  e  <?  i  a 
tlin)Uf;lii""^(>- 
traumatic  spasms  of,  differen- 
tiiited  from  cephalic  tetanus 
with  facial  paral\sis,  727. 
Facial   expiession   in   tetanus,   7S9, 

794. 
Facial  nei'ves,  lesions  of  in  svphilis, 

(■);«. 
I'acial  ueuralj^ia,  spasmodic  differ- 
entiated from  cephalic  tetan- 
us with  facial  paralysis,  727. 
Facial  paial^sis,  in  cephali<'  tetanus. 
(Sec    Cephalic  tetanus  with 
facial  i>aralysis.) 
with    paraly.sis    of    the    h\-po- 
ti;lossal,  743. 
in  syphilis,  oSti. 
«:reatment  of,  040. 
F:rce.s,  isolation  of  ty])lu)id  bacillus 
from,  1  OS. 
l)aratyphoid  injection  in,  250. 
typhoid  bacilli  in,  179. 
' '  Famine  fever,"  4S:^. 
Fatijiue  a  i)redisposinff  cause  of  ty- 
phoid infection,  173. 
and  d.N'sentery,  344. 
in  proi)hylaxis  in  typhoid.  220. 
Febiile   form   of   typhoid   fever   in 

infants,  14. 
Febrile  jiia.stric  deran^oment  in  first 
invasion  of   primary   paliid- 
ism  of  malaria,  9ol. 
diagnosis  of,  953,  954. 
general  symptoms  in,  951,  952. 
pulse  in,  953, 
temperature  in,  95"5. 
in  typhoid,  11. 
Febrile  infections  simulating  tvph- 
oid  fever,  100. 
reactions   following  vaccination, 
271,  277  (note). 
Female  genital  organs  in  tvphoid, 

73. 
Female  labour  and  svphilitic  mor- 
bidity, 519. 
Ferran,    prophylactic    vaccination 

agauist  cholera,  448,  449. 
Fever,  in  malaria,  949. 

in  secondary  paludism,  100<S. 
irregular,  1(*1 1. 
isolated  fits  of,  1010. 
quotidian  intermittent,  1010. 
septan  type  of,  1010. 
tertian  intermittent,  1008. 


Fever,  in  mahuia,  in  second  phase 
of  primary-  i)aludism,  902 
apvrexia   between   attacks   in, 

907,  90S. 
iiregular  fever  in,  907. 
isolated  attacks  in,  f)05. 
ociau'i'dice  of  attacks  in,  907. 
(|Uotidian    intermittent    fever 

in,  9()5. 
remitlent   continued   fever  in, 

902. 
tei'tian  attacks  in,  905. 
I.Y>\.p,.    reduction  in  typhoid  affec- 
tions, 133. 
by  external  applications,  133. 
affusions  in,  133. 
baths  in,  134. 

Jirand's   method   of   giving, 

134. 
hot,  137. 
warm,      graduall.y      chilled, 

130. 
warm  or  tepid,  130. 
compresses  in,  138. 
rectal  enemata  in,  138. 
rectal  instillations  in,  138. 
refrigeration    by    cold    air   in, 

138. 
sponging  in,  133., 
wet  packs  in,  134. 
by  internal  medication,  140. 
antipyrine  in,  140. 
eryogenine  in,  140. 
pyramidon  in,  140. 
riuinine  in,  140. 
Fever,  typhoid(,See  Typhoid  fever), 
typhus,    99.      (See    also  Typhus 

exanthematicus.) 
importance    of    early    diagnosis 

90. 
Malta,  101,  232. 
Mediterranean,  101. 
paratyphoid,  80  et  seq.      (See  also 

Paratyphoid  fever.) 
serum  therapy  for,  148. 
Finger,  500. 
Fish,  transmission  of  cholera  vibrio 

by,  435. 
Fixation  abscess,  141. 

of  complement  in  syphilis,  554. 
in  test  for  typhoid  affections, 
121. 
Flexner  bacillus  of  dysentery,  dif- 
ferential  characteristics   of, 
322. 
Flies,  agents  of  contagion  in  chol- 
era, 429-430._ 
in  dyscutory,  354-355,  374. 


1072 


INDEX 


Flics.aKcntsof  antiiirioii  in  tvphoid, 
217,    2:i(),    240,     H    .srq.,    249, 

25'). 
moc-hanical    i)r()tcctioii    against, 

240.  240. 
IHuid,  autiscptic.  in  syphilis,  654. 
Follifular  syphilidc's,  57s,  045. 

tubci'culido,  579. 
Fonlana,  551. 
Food  as  sourco  of  dy.scMitci'v  inf(H'- 

tioii,  354. 
fresh,  in  dv.sonterv  pjopln  laxis, 

869.  874. 
paratyphoid  infoftion  in,  257. 
Forceps,  jjre.ssure,  0)54,  055. 
Formuhi,  Renault's,  097,  09S. 
FunnuUiire       />h(irfiia(:(i)lu/iic       dcs 

liopitdux  mililiiircs,  .594,  595, 

.";90.  00:5,  ()04,  000. 
Foiulro\ant  form  of  cholera,  895. 
Foamier,    Alfred,    525,    527,    52S, 

581,  548,  557,  505,  5S0,  091, 

095. 
statistics    of,     in    s.\-pliilis,     52S. 
tal)le    of    tertiary    symptoms    in 

syphilis  of,  525. 
urticarial  roseola,  574,  575. 
Fractures  of  skull,   manifestations 

of,     coijhalic     tetanus    with 

ophthalmoplegia       differen- 
tiated from,  789. 
France,   frecjuency  of  pai'atyplioid 

fever  in.  254. 
typhoid  fever  prevalent  in,   150 

et  neq.  215.    (C/.  Epidemics.) 
water  supi)ly  of,  212. 
Franco-Prussian     War,     dvsenterv 

in,  840. 
typhoid  castas  in,  101. 
"  Fjank"  fehi-ile  attacks  in  second- 
ary   paludism     in     malaria, 

1005. 
Free  disi)cnsaries  for  t?eatment  of 

.syphilis,  090. 
Free    iJrostitutif)n    and    treatment, 

700. 
French  and  Flemish  soil   contami- 
nated, cause  of  tetanus,  i)20. 
French    armv,    tvphoid    fever    in, 

158,  109,  172,  202. 
Front,  army  treatment  at  the,  049. 
Fulininatinjr  form  of  bacillary  dys- 

entery,  800. 
FurlouKh,_  syi)hilitic   patients   and, 

075,  070. 
Furuneulosis,  79. 

CJaertner's  bacillus,  259. 


GaU-ljladder,   seat   of  infection  of 
dysentery  Ixicilli,  84S. 
typhoid  l)acilliin,  17S,  ISS. 
Galyl,  080,  ()87. 
(uuuetes,  940. 

chronicitv     of     malaria    due    to 

resistance  of,  942-948. 
of  Plasmodium  falciparum,  1080. 
of  Plasmodium  malaria\  1088. 
of  Plasmodium  vivax,  1027. 
parthenoffenesis  of,  942. 
(Jans^es,  bactericidal  jjrojjerties  of, 

for  cholera  vibiicj,  481. 
(ian^rene  complicating  typhus  ex- 
ant  hematieus,  465. 
in  cholera,  892. 
cutaneous,  892. 
of  extremities,  892. 
visceral,  892. 
in    svijhilis,    of    u;enital    organs, 

557.  502,  508. 
in  t\"ijhoid  of  skin,  78. 

pulmonary,  40. 
sjiumetrical,  in  second  phase  of 
primary    paludism    in    ma- 
laria, 987. 
Gangrenous  dysentery,  801. 
(jart^les,  044. 

Gas  gangrene   coincident   with   te- 
tanus, 920. 
Gastral^ia,  594. 

Gastric    derangement,    febrile,    in 
fir.st     invasion     of     primary 
paludisr.i  of  m.-ilaria,  951. 
diagnosis  in,  958,  954. 
general  symptoms  in,  951 ,  952. 
pulse  in,  958. 
temperature  in,  058. 
Gastric  symptoms  in  tyi)hoiil  fever, 

29. 
Gastric  typhoid,  9. 
Gastro-bilious  syndrome  in  second 
phase  of  primary  paludism 
in  malaria,  974. 
Gastro-iutestinal  disease,  254. 
disorders,  <585. 
form  of  typhoid  fever,  in  infants, 

18. 
troubles  in  Avar  time,  282. 
Gaucher,  505,  588. 
Gautier,  .\rmand,  012. 
Generalised     exfoliative     erythro- 

dermia,  085. 
Gengou,  554. 
Genital  herpes,  557,  558. 
Genital  organs  in  syphilis,  excoria- 
tions of,  502. 
gangrene  of,  502. 


INDEX 


1073 


Genital  organs  in  typhoid,  fenuilo, 
73. 

Gonito-uriiiarv  svsteni,  the  hyyieiie 
of,  127. 

Germ  carriers,  researches  on,  1S7. 

German  Expedition  against  the 
Herroros,  mortality  from  ty- 
phoid fever,  102. 
method  of  injection  of  anti- 
tetanic  serum  foi-  treatment, 
875. 

Germans,  susceptil)ility  of,  to  ty- 
phoid fever,  lf'9. 

Germany,  cholera  in,  411. 

most    important    seat    of    para- 
typhoid A  and  B,  254. 
typhus  in,  478,  480. 

among  prisoners,  484. 
vaccination   against   cholera   in, 
450. 

Giant  chancre,  540. 
plaques,  584. 

Gibert's  Pityriasis  rosea,  575,  576. 
syrup, 594, 595. 

Giemsa's  method  of  examination, 
550,551. 
solution,  551. 

Giroux,  588. 

Glands,  salivary,  72. 

Cilandular  trouble,  72. 

(ilass  syringe,  652. 

Glossitis,  marginate  exfoliative, 
583 

Godart,  M.  Justin,  506.  535.  692. 

Gonorrhoea,  increase  of,  504. 

Gonorrhoeal  arthritis,  520. 

Govaerts,  Mme.,  510. 

Granular  roseola,  574. 

Grave  icterus,  588. 

Greek  army  in  Balkan  war.  vacci- 
nation against  cholera  in, 
450. 

Grey  oil,  injections  of,  600,  602, 
603. 

Guinea-pigs,  result  of  pure  cul- 
tures of  typhoid  bacillus  in, 
40. 

Gumma,     531. 

Gummatous  iritis,  587. 

Gurgling,  30. 

Hiematozoa  of  malaria,  939. 

anopheles   mosquito  medium  of 

inoculation  with.  939. 
.asexual   development  of,  in  hu- 
man body  (schizogony),  939. 
effects     of     quinine     on     ele- 
ments in,  941. 


H«matozoa    of    malaria,    asexual 
development  of,  in   human 
l)ody,  element.s  formed  in: 
anneboid  bofly,  940. 
gametes,  940. 
merozoite,  941. 
rosette  body,  941. 
schizont,  939. 
parthenogenesis   or    retrogres- 
sive schizogony  in,  942. 
diagnostic  characters  of,  1025. 
chart,  1032. 

of     Plasmodium     falciparum, 
1029. 

gametes  of,  1030. 
schizont  of,  1029. 
of  Plasmodium  malaria?,  1031. 
amoeboid  bodies  of,  1031. 
gametocytes  of,  1033. 
rosette  bodies  of,  1031. 
schizonts  of,  1031. 
of  Plasmodium  vivax,  1025. 
amoeboid  body  of,  1027. 
blood  corpuscles  in,  1025. 
gametes    (or    gametocytes) 

of,  1027. 
parasite  itself  in,  1025. 
schizont  of,  1025. 
in  relapse,  942. 

sexual       development      of,       in 
Anopheles  mosquito  (sporo- 
gony),943. 
elements  formed  in: 
flagellated  bodies,  944. 
macrogametes,  943. 
microgametes,  943. 
oocyst,  945. 

ookinete  or  zygote,  944. 
sporozoite,  945. 
Ha?maturia  in  syphilis,  648. 
HiBmoglobin  in  typhoid,  45. 
Hiemoglobinuric  fever,  bilious,  in 
secondary  paludism  in  ma- 
laria, 1011. 
attack  of,  1013. 
blood  in,  1014. 
course  of ,  1014,  1015. 
icterus  in,  1013. 
occurrence  of,  1013. 
urine  in,  1014. 
early  bilious,  in  malaria,  989. 
Hemolytic  icterus,  588. 
HiBmorrhage  in  typhoid  fever,   9, 
40. 
intestinal,  32. 

in  paratyphoid  fevers,  88. 
rupture  and,  74. 


1074 


INDEX 


HiEmoiTh.a<?i<-  nnirniiu  in  seoonrl  at- 
tacks   ill    primary    invasion 
in  nialari:},  971. 
early  appearance  of,  972. 
quinine  in,  972. 
symptoms  of,  971. 
HaMnorrhajiiic  dysentery,  3();i. 
pleurisy,  40. 
lyi)hoi(l  fever,  32. 
Hair,   treatment  in   typlioid   fever, 

127. 
Haffkine,  jji'ophylactic  vaccination 

against  cholera.  449-4.')(). 
Hallucinations,     auditory,     in     sy- 
philis, (V.Vi. 
Wiimhnvii.,  cholera  at,  4."33. 
Hands  as  carriers  of  dvsentery  in- 
fection, 347. 
Hayem,  solution  for  venous  trans- 
fusion in  cholera,  407. 
Headache  in  syphilis,  524,  585,  620. 
and  lumbar  puncture,  585. 
treatment  of,  (540. 
in  typhoid,  02,  147. 
Hearinji;  in  typhoid  fever,  00. 
Heart  disease,  typhoid  fever  in,  19. 
Heart     disorders    in    paratyphoid 

fevers,  84. 
Heat,    in   prophvlaxis   of   tvphoid, 
220. 
its   influence   on    typhoid    fever, 
160. 
Hectarfryre,  012. 
Hemi-athetosis,  ()3. 
Hemiplegia  iu  svphilis,    5S5,    5S0, 
021.047. 
treatment  of,  047. 
Hepatic    ahsce.sses    in    dvsenterv, 
307,301. 
in  typhoid  fever,  07. 
Hepatitis,  ama'hic,  360. 
Tmppiu-ative,  305-300. 
Heredity,  maternal,  mixed  and  pa- 
ternal, in  syphilis,  528. 
Hel-pes,  genital.  557,  55S. 
Mauriac;'s  neuralgic,  5.58. 
prechancrous,  558. 
Herreros,       German       Expedition 

against,  typhoid  in,  102. 
Herxheimer's  reaction,  02U,  035. 
His  bacillus  of  dysentery,  differen- 
tial characteristics  of,  322. 
Hoechst     Cliemical     Dve     Works, 

013,615. 
HofTmami,  549. 

ILxspital  patients,  in  svphilis,  ad- 
vice to,  168. 
and  syphilitica,  673. 


Hospital,    munition  workers    and, 
074. 
services,  additional,  692,  693. 
treatment  and  offic^ers,  074. 

Hospitalisation,  locality  of,,  076. 

Hospitals,  Broea,  Cochin  and  St. 
Louis,  691),  695. 

Hot  weather,  and  cholera,  414. 

Houses,  licensed,  090,  697,  699, 
700. 

Hudelo  and  .Teauselme,  690. 

Humidity  an  aid  to  development 
of  tetanus,  832. 

Humoral  reactions  in  typhoid  in- 
fections, 118  ct  fie.q. 

Hydriemia  accompanying  anremia 
in  second  attacks  of  primary 
invasion  in  malaria,  970. 

Hyflrochloric  acid,  use  of,  in  anti- 
tetanic  serotherapy,  865. 

Hydrogen  pei-oxide,  destruction  of 
tetaiuis  toxin  by,  848. 
in  syphilis.  540. 

Hydropliobic  form  of  cephalic  te- 
tanus, 711. 

Hydro-thera|)eutic  measures  in  ty- 
phoid fever,  133. 

Hvgiene,  advice  as  to,  in  svphilis, 
680,  007. 
in  treatment  of  tetanus,  887. 
in  typhoid,  importance  of,  in  the 
army,  242. 
of  the  dwelling,  227. 
public  ignorance  of,  229. 

Hyoscamus  in  tetanus,  889. 

Hyperpyretic  form  of  typhoid,  12. 

Hypertrophied  tonsils  in  syphilis, 
584. 

Hypochlorite  of  sodium  solution, 
044. 

Hypochlorites  as  water  purifiers, 
237. 

Hypoglossal    nerve,     cephalic    tet- 
anus with  paralysis  of,  742. 
summary  of,  916. 

Hvsteria,  ocular  derangements  in, 
740. 

Hysterical  ptosis,  740. 

Hystero-traumatism,  ocular  m  uii- 
festations  of,  740. 

Icterus,  accompanying  anaemia,  in 
second  attacks  in  primary 
invasion  in  malaria,  972. 

examination  of  blood  in,  973. 

gravis,  103,  588. 


INDEX 


1075 


Icteri,  hsemolytif,  5SS. 
ill  cholera,  393. 

infective,    in    second     plnise    of 
primary    paludisni    in    ma- 
laria, 976. 
mild,  67. 

secondary  syphilitic,  587. 
syphilitic,  635,  647. 
Imnmnity  conferred  by  attack  of 
bacillary     dysentery,     344- 
345. 
by  dead  cultures,  375. 
by  cholera  vaccine,  448-453. 
Incubation  period  in  sypliilis.  572. 
of  simple   chancre,    536,    537, 

560. 
second,  572. 
of  paratyphoid  fever,  81. 
of  typhoid  fgver,  3,  7. 
India,  cholera  in,  410. 
Indirect  contagion  by  patients  or 
carriers    in  typhoid,  204  ct 
seq. 
Individual  instruction,  in  svphilis, 

678,  679. 
Indurated  chancre,  540. 
Induration,  chancrous,  562. 

papyraceous,  541. 
Infants,  rarity  of  typhoid  fever  in, 
12. 
three  forms  of  typhoid  fever  in, 
13. 
Infection    in    syphilis    and    prog- 
nancy,   maternal,   528,   529, 
Vincent's  spirillar,  585. 
in  typhoid,  259. 
Infectious  theory  of  origin  of  ce- 
phalic tetanus  with  ophthal- 
moplegia, 735. 
wounds    of    face,    differentiated 
from  cephalic  tetanus  with 
facial  paralysis,  728. 
treatment  of,  728. 
Infective  chancre,  564. 
Infective      endocarditis,      typhoid 

form  of,  103. 
Infiltration     and     tumefaction     of 
chancre,  542. 
basal,  562. 
Inflammatory  typhus,  466. 
Influenza    and    typhoid    fever,   19, 
98. 
and  typhus,  470. 
differentiated  from  typhus,  470. 
Ingestion,    in    syphilis,    mercurial 

medication  by,  594. 
Injections,  mode  of,  in  svphilis,  655, 
656,  657,  658,  659,  660,  661. 


Injections   of  cyanide  of  mercury, 
640,  642. 

precautions  after,  603,  664. 
of  grey  oil,  600,  602,  003. 
of  novarsenol)enzol,  644,  645. 
periodicity  of,  628. 
pre(!autions  after,  664,  665. 
vechicle  for,  616,  617. 
Injections,    .soluljle   and    insoluble, 
600,  001,  602,  604,605. 
stages  of,  653,  656,  657,  659. 
in  typhoid,  in  septictemia,  141. 
of  normal  saline  solutions,  143. 
tec'hni(iue  of,  270. 
Injury  of  nerve  filament  in  svphilis, 

662. 
Inoculation  of  simple  chancre,  559. 

oF  syiihilitic  chancre,  542. 
Insidious  typhoid,  11. 
Insomnia  in  typhoid  fever,  59. 
Inspection,  medical,  504,  671,  672, 

673. 
Instillations,     rectal,     in     typhoid, 

138. 
Instruction  as  to  venereal  danger  , 

682. 
Instruments  in  syphilis.  652. 
Insurance  statistics,  526. 
Intercostal  neuralgia,  633. 
Intermediate  bacilli,  typhoid  affec- 
tions and,  117. 
Intermittent  cure,  Fournier's,  598. 
International    Bureau  of   Hygiene 
on  bacteriological  diagnosis 
of  cholera,  442. 
Intestinal    complications   in   para- 
typhoid fevers,  88. 
haemorrhage,      in      paratyphoid 
fevers,  88. 
in  typhoid  fever,  32,  145. 
lavage,  144. 

perforation  in  typhoid,   33,    89, 
145. 
treatment  of,  145. 
symptoms  in  typhoid  fever,  30. 
syndromes    in   second    phase    of 
primary    paludism    in    ma- 
laria, 981. 
Intestine,  cicatricial  strictures  of, 
in  dysentery,  304. 
typhoid  bacilli  in,  176. 
Intra-muscular  injections  in  syph- 
ilis, of  calomel  oil,  604. 
of  mercury,  594,  600,  602. 
of  novarsenobenzol,  619. 
injections  in  tetanus,  923. 
of  antitoxin,  of  doubtful  value, 
924. 


1076 


INDEX 


Intraparietal  penetration,  G61. 
Iritra-rectal  instillations,  139. 
Intra-spinal  injections  in  tetanus, 

923-92G. 
Intravenous  injections  in  syphilis, 
advantages  of,  609. 
apparatus  for,  052. 
difficulties  of,  660,  661. 
inconveniences  of,  609. 
mode  of  operation  in,  655. 
of     cvanide     of     niercurv,     608, 
610,611,  644. 
dose  for,  611. 
precautions  after,  683. 
of  mercury,  60S,  609. 
of      neosalvarsan,       precautions 

after,  664. 
operative  accidents  in,  661. 
techni(|ue  of,  697,  60S,  652. 
Intravenous  injections  in   tetanus, 

923. 
Iodide  of  potassium,  593,  594. 

of  sodium,  593. 
Iodides,  593,  594. 
Iodine  in  syphilis,  5!)1,  593,  644. 

gargle,  644. 
lodo-mercuric  cacodylate,  612. 
Ipecacuanha  in  dysentery,  32S-329. 
Iritis  in  syphilis,  5S6,  5.S7,  5!^8. 
and  irido-choroiditis,  621. 
treat yieut  of,  647. 
Irrigation  in  dysentery,  330-334. 
Is(jlation    in    contagious    syphilis, 
675. 
of  svphilitic  carriers,  670,  673. 
675. 
in  typhoid,  necessity  of,  232,  243. 
in  dysentery,  370,  373. 
Italian  licen.sed  houses,  700. 
Italian   sterilising  method  of  quin- 
ine administration  in  the  in- 
tervals in  secondary  palud- 
ism  of  malaria,  1052. 
Itali'    and    anti-venereid    strugi^le, 
688. 

Jacond,    amphibolic    stage    of,    in 

typhoid  fever,  55. 
Japan,   epidemic   of  dvsenterv  in, 

358. 
Japane.se,    vaccination    of,    against 

dysentery,  375. 
Japanese  army,  the,    few   ca.^es  of 

typhoid  fever  in,  16i). 
Jaundice  in  cholera,  393. 
in  syj)hilis,  524. 
in  typhoid,  66,  67. 


Jeanselme  and  Hudelo.  690. 
and  Verues,  556. 

Job's  method  of  quinine  adminis- 
tration in  the  intervals  in 
secondary  paludism  of  ma- 
laria, 1051. 

Kadarrov,  observations  on  vacci- 
nation against  cholera,  451. 

Kidney   disorders    in   paratyphoid 
fevers,  89. 
troui^le  in  typhoid  fever,  69. 

Kitasato,  isolation  and  cultivation 
of  tetatms  bacillus  by,  821. 

Tvabarr:i(iue's  solution,  331,  664. 

Lactation,  cholera  and,  396. 

Ladysmith,  Siege  of,  162.    . 

Landouzy,  518. 

Landry's  disease,  64,  633. 

Landsteiner,  566. 

Largin,  551. 

Ijaryngeal  t:omplicatious  in  second 
phase  of  primary   paludism 
in  malana,  995. 
of  typhus  exanthematicus,  465. 

Laryngo-typhoid,  3s. 

Larynx,  lesions  of,  in  typhoid,  38. 
necrosis  of,  in  typhoid,  38. 

Late-appearing  tetanus,  inc\il)ation  . 
period  of,  784. 
explanation  of,  784-785. 
incubation  period  of,  784. 

Latent  form  of  tvphoid,  11. 
spinal  meningitis,  634. 

Laval,  case  of  tetanus  of  left  lower 
extremity,  760,  792. 
case    of    tetanus   of   right   lower 
extremity,  763. 

Tjavertui,  discovery  of  protozoon 
of  mrdaria  l)y,  939. 

Leave  and  venereal  disease,  682. 

Lectures  on  venereal  disease,  682, 
683,  684,  685,  686,  687. 

Legendre  and  Hazin,  plaque?  of, 
576,  577. 

I^egouot,  ca.se  of  tetanus  in  fingers, 
780. 

Lenticular  rose  spots,  76,  83,  93. 
isolation     of     tvphoid      bacillus 
from,  109. 

Lepine  and  Sarvonat.  case  of  ce- 
phalic tetanus  with  oph- 
thalmoplegia, 731. 

Lesions,  in  syphilis,  artificially  in- 
duced. 583. 


INDEX 


1077 


Lesions,     in     syphilis,    cutaneous, 
573,  620. 

pruriginous,  5So. 
ulcerative,  524. 
diagnosis  oi  tertiary,  5S  9,  5'.)(). 

of  syphilitic,  5.30. 
of  auditory  nerve  and  hiliyriiilh, 

586. 
of  lips,  5S2. 

of  niusous  inenil)ranes,  583,  584. 
of  muscles  and  hones,  648,  649. 
of  nails,  582. 
of  oculo-motor,  optic,  and  facial 

nerves.  633. 
of  palate,  531. 
of  pharynx,  584. 
of  skin,  ulcerous,  645. 
of  spinal  nerves,  633. 
of  tonsils,  584. 
optical,  580. 
secondary,  619. 
i^oerous,  562. 
Lesions,    contractures    or    pseudf)- 
contractures  following,  niou- 
oplegic  form  of  local  tetatuis 
differentiated  from,  799. 
Letulle  and  Berj^eron,  524. 
Leucocytes  in  typhoid,  46. 
Leucoplakia  in  svphilis,  .383,  584. 

590. 
Levator  palpehnv  superioris,  paral- 
ysis  of,   in   aphalic    tetanus 
with  ophthalmoplesiu,  733. 
Lice,  campaign  against,  497-503. 
inoculation  of  virus  of  t\-phus  hv, 
490. 
method  of,  492. 
Licensed  houses,  696,  697,  699,  700. 
Italian,  700. 
.Japanese,  700. 
Lichen  scrofulosum,  579. 
syphilitic,  578. 
Wilson's,  578,  584. 
Lichenoid  svphilides.  578,  645. 
Light   therapy   in  local   treatment 
of  wounds  for  prevention  of 
tetanus,  850. 
action  of, on  bacillus  and  toxin, 

850. 
process  of,  850-851. 
Limbs,  local  tetanus  of,  745. 
atypical  forms  of,  745. 
cases  of,  746. 
summary  of,  917. 

monoplegic  type,  917. 
paraplegic  type,  918. 
Lipothymia,  635. 


Lips,  adenopathy  of,  570. 

chancre  of,  568,  569,  643,  644. 
Liquor,  van  Swieten's,  594. 
Liver,  abscess  of,  in  ama'i)ic  d>-.sen- 
tery,  307. 
>-cllovv  atrophy  of,  635. 
Liver  and  gall-bladder  in  typhoid 

fever,  66. 
Livierato,  treatment  of  cholera  in 

Balkan  war,  404. 
Lobar      pneumonia.     .See      Pneu- 
monia. 
Local    tetanus,    abdomino-tlioracic 
form  of,  811. 
case,  P.  L.  Marie,  811. 
development  of,  815. 
mode  of  entrance  in.  814. 
pathogenesis  of,  815. 
attenuated  forms   of,   with  slow- 
development  and  prolonged 
inculjation,  817.  _ 
pathogenesi.s  of,  81/. 
symptoms  of,  817. 

facial  expression  in,  818. 
hyper-excitability    of    nms- 

cles  and  nerves  in,  819. 
nmscular  hypertonia  in,  SIS. 
definition  of,  781. 
development  of,  837. 

nature       of,       sui)-acute       or 

chronic,  S37. 
period  of  onset  of,  838- 
second  period  of.  or  period  of 
permanent,  uon-i)ainful  con- 
tractures, 838 
third  j)eriod  of,  839. 
etiology  of,  821.  ■ 

adjuvant  factors  in,  832. 

atmospheric  conditions,  832. 
cold,  832. 
humidity,  832. 
chemical  substances,  833. 
.seitondary  infection.  832. 
causal     asrent    in    (Nicolaier  s 
liacilUis),  821. 
biological  properties  of.  823. 
agglutinability  ui,  824. 
gas  formaiion  ui.  824. 
hLemolysin  in,  824. 
endol  formation  in,  824. 
vitality  in,  823. 
cultures  of,  822. 
experimental  pathogenic  ac- 
tion of,  824. 
inoculation  with  pure  cul- 
tures in,  825. 
inoculation   with   tetaiuf- 
eroub  pus  or  soil  in,  825. 


107S 


JNDEX 


Local  tetanus,   otifjlogy  of,  rausal 
agont  in,  exporimental   patho- 
Konic  action  of,   isolation  and 
cultivation  of,  S21. 
mobility  of,  S22. 
morphology  of,  S21. 
slaininji  of,  S22. 
diroct  contact  in,  S34. 
habitat  of  l)acillus  in,  <S2S. 
soil  as,  S28. 

in    European   war   re<>;- 
ions,  X2n. 
straw  as,  S3(). 
infection  of  wound  in,  action 

of,  830. 
nature  of  wound  in,  S31. 
situation  of  wound  in,  S31. 
toxin  in,  826. 

method    of    preparation    of, 

826. 
mode  of  action  of,  827. 
nature  and  properties  of,  826. 
forms  of,  780. 
frequency  of,  820. 
history  of,  780. 

in  abdomen,  late-appeariuj?,  772. 
in  neck,  case,  770. 
nionoplegic  form  of,  783. 
diagnosis  ot,  790. 

bacteriological  examination 
for  bacillus  in.  796-707. 
differential  diagnosis  of,  797. 
from  acute  strychnine  poi- 
soning, 802. 
from  contractures  or  pseudo- 
contractures        following 
lesions,  799. 
from  contractures  of  tetany, 
800. 

Chvostek's  sign  in,  801. 
forcible      extension      and 
flexion    of   lower  linibs 
in,  802. 
hyperexcitability  of  mus- 
cles and  nerves  to  gal- 
vanism in.  802. 
Trousseau's  sign  in,  801. 
Wei.ss's  sign  in,  801. 
from  excitation  or  irritation 
of  motor  and  mixed  nerves 
due  to  lesions,  798. 
from  hysterical  contractures 

803. 
from  incomplete  hemiplegia, 

798. 
from  spasmodic  monoplegia 
of  ceror)ral  or  medullary 
■origin,  796. 


Local  tetanus,  monoyligic  form  of, 
period  of  acuue  in,  790. 
l)lood  in,  795. 

cerebro-spinal  fluid  in,  795. 
contractures  in,  7\)(\  791. 
clonic  movements  in,  791. 
generalized      tonic      form 
(rigidity)  of,  791-793. 
general  indications  in,  793. 
facial  aspect  in.  794. 
hypersensitiveness  in,  794. 
pulse  in,  794. 
respiration  in,  794. 
urine  in,  794. 
l)ain  in,  790. 
reflexes  in,  795. 
summary  of,  795. 
period  of  incubation  in,  793. 
in      early      or      precocious 

tetanus,  793. 
in    late-appearing    tetanus, 
794. 
due    to   surgical    trauma- 
tism, 794,  795. 
explanation  of,  794,  795. 
period  of  onset  in,  785. 

general  symptoms  in,  788. 
exaggeration    of    reflexes 

in,  789. 
facial  expression  in,  789. 
temperature  in,  789. 
local  signs  in,  786. 
cramps  in,  787. 
pain  in,  786. 
skin  in,  786. 
spasms  in,  786,  787. 
stiffness  in,  788. 
summary   of  symptoms  iji, 
790. 
paraplegic  form  of,  805. 
diagnosis  of,  809. 
differential  diagnosis  of,  from 
cerebro  -  spinal    meningitis, 
809. 
symptomatology  of,  805,  808. 
in  inferior  type,  806. 

contractures  of  limbs  in, 

806. 
muscular  rigidity   of  ab- 
dominal wall  in,  806. 
in  superior  type,  807. 
pain  in,  807. 
reflexes  in,  808. 
teniperature  in,  808. 
ty()es  of,  805. 
paraplegic  on.set  of,  78 L 
pathogenesis  of,  834. 
factors  in,  835. 


INDEX 


1079 


Local     totanufl,     pathofitoncis    of, 
mode  of  arrest  in,  S35. 
process  of,  S34. 
projiiiosis  of,  840. 

abdominal   muscular   contrac- 

tvire  in,  842. 
detilutition  in,  843. 
in  atypical  form,  840. 
localization  in,  840. 
period  of  incubation  in,  841. 
temperature  in,  840. 
in  classical  form,  841. 
pulse  in,  842. 
temperature  in,  842. 
other  bacteria  in,  843. 
summary  of,  843. 
TiOeffler's  bacillus,  572. 
Losch,     discovery     of     dy.^enteric 

amcjeba  by,  316. 
Lotion,  647. 
Luargol,  637,  638. 
Lumbar  picture,  633.  634. 
Lymphatic  glands,  73. 
Lymphitis,  544. 
Lymphocytosis,  633. 

cerebjo-spinal,  580,  586. 

Macedonia,  malaria  in,  939. 

varieties  of  mosquitoes  in,  947. 
Macular  roseola,  574. 
Magnesium    sulphate    in    curative 
treatment  of  tetanus,  894, 
925. 
action  of,  on  circulation,  897. 
experimental  action  of,  894. 
influence    of,    on    body   temper- 
ature, 896. 
mechanism    of    action    of ,    and 
dosage,     897. 
clinical  results  in,  900. 
experimental  results  in,  900. 
intrarachidian    injections    in, 

899. 
intravenous  injections  in,  897. 
subcutaneous     injections     in, 
897. 
mode  of  administration  of,  and 
dosage,  902. 
intrarachidian    injections    in, 

903. 
intravenous       injections      in, 

904. 
subcutaneous     injections     in, 
902. 
Malaria,  clinical  study  of,  949. 
primary  paludism  in,  949. 
secondary  paludism  in,  950. 


Malaria,  dj'.senterv  associated  with, 
311,469,  1016. 
in  Macedonia,  939. 

gravity    of,    factors    cau.sing, 
947-948. 
parasitological       diagnosis       in, 
1018. 
hirmatological  signs  in,  1033. 
melaniferous   leucocytes  in, 

1033. 
mononucleosis  in,  1033. 
luematozoa      in,       diagnostic; 
characters  of,  939. 
chart,  1032. 

of   Phxsmodium   falciparum, 
1029. 
gametes  of,  1030. 
schizont  of,  1029. 
of     Plasmodium      malaria?, 
1031. 
amoeboid  bodies  of,  1031. 
gametocytes  of,  1033. 
rosette  bodies  of.  1031. 
schizonts  of,  1031. 
of  Plasmodium  vivax,  1025. 
amoeboid  body  of,  1027. 
blood  corpuscles  in,  1025. 
gametes  (or  gametocytes) 

of,  1027. 
parasite  itself  in,  1025. 
schizont  of,  1025. 
method  of  making  blood  film 

in.  1018. 
methods  of  staining  in,  1019. 
Laveran's     panchrome     in, 

1024,  1033. 
Sene  vet's     borax-eosin-blue 

stain  in,  1021. 
Tribondeau's     bi  -  eosinate 

stain  in,  1019-1021. 
water  used  in,   precautions 
regarding,  1022. 
Langeron's     method      of 

testing  in,  1022. 
results      with       ordinary 
water  in,  1023. 
with      deep      staining, 

1024. 
with      faint      staining, 

1023. 
with  intermediate  stain- 
ing, 1024. 
obtaining  blood  for,  1018. 

thick  drop  method  of,  1033. 
preservation  of  sUdes  in,  1019. 
parasitology  of,  939. 

Anopheles    mosquito  medium 
of  inoculation  in,  939. 


1080 


INDEX 


Malaria,    asexual   development  of 
parasite    in     human     body 
(schizogony  in,  939. 
effect    of    quinine    on    ele- 
ments in,  941. 
elements  formed  in: 
amoeboid  body,  940. 
gametes,  940. 
merozoite,  941. 
rosette  body,  941. 
schizont,  939. 
parthenogenesis     or     retro- 
gressive    schizogony     in, 
942. 
relapse  in,  942. 

sexual  development  of  parasite 
in       Anopheles       mosquito 
(sporogony)  in,  943. 
elements  formed  in: 
flagillater  bodies,  944. 
macrogametes,  943. 
microgametes,  943. 
oocyst,  945. 
ookinete  or  zygote,  944. 
sporozoite,  94.5. 
Malaria,  primary  paludism  in,  951. 
clinical  study  of,  949. 
first  invasion  in  svndromes  of, 
951. 
attenuated    form    of    inva- 
sion,    febrile     malaise     and 

fatigue  in,  957. 
continued  fever  of  typhoid 
character  in,  954. 
differentiation     of,     from 

typhoid  fever,  957. 
general  symptoms  of,  9.54. 
pulse  in,  955. 
temperature  in,  955. 
febrile  gastric  derangement 
in,  951. 
diagnosis  in,  953,  954. 
general  symptoms  in,  951, 

952. 
pulse  in,  953. 
temperature  in,  953. 
quotidian  intermittent  fever 
in,  958. 
second   attacks   or  relapse   in 
960. 
defaced    paludism    in,    9G1, 

102. 
masked  paludism  in,  1003. 
pernicious  997. 

algid  form  of,  1001. 

characteristic     api)ear- 
ance    of    patient    in, 
1001. 


Malaria,  primary  paludism  in, 
second  attack  in,  pernicious, 
in  algid  form,  initial  symp- 
toms in,    1001. 

secondary     alimentary 
disturbances, in,  1002. 
cerebral  form  of,  999. 
apoplectic,         isolation 

type,  999. 
convulsive      meningeal 
type,  1000. 
etiology  of,  997. 
forms  of,  998. 
occurrence  of,  998. 
syndromes  of  viscera!  local- 
isations in,  908. 
aniemic     syndromes     in, 
969. 
in  anaemia,  typical  form 

of,  969. 
in  antfimia  with  hydre- 
mia, 870. 
with  icterus,  972. 
in  haimorrhagic  anaemia, 

971. 
in   splenoniegalic    ana)- 
mia,  972. 
auditory        disturbances, 

997. 
cachectic  syndrome,  983. 
aniemia  in, 98.3. 
digestive    disturbances 

in,  984. 
prognosis  of,  985. 
cai-dio    -     vascular     syn- 
dromes, 987. 
erythromelalgia  in,  988. 
Ravnaud's    disease    in, 

987. 
symmetrical     gangrene 
'  in,  987. 

visceral    circulation   in, 
disorders  of,  9H8. 
gastro-hepatic  syndromes 
in,  974. 
gastro-bilious  forms  of, 

974. 
infective    icterus    form 
of,  976. 
intestinal  syndromes,  980. 
diarrhaac  symptoms  in, 

981. 
dyisenteriform      s  y  n  - 
drome  in,  982. 
larvngeal     complications, 

995. 
nervous     manifestations, 
989. 


INDEX 


1081 


Malaria,  primary  pahulism  in, 
second  attacks  in,  syn- 
dromes of  visceral  localisa- 
tions in,  nervous  manifesta- 
tions, focal  symptoms  in, 
991. 

mental  disorders  in,  992. 
neuralgia,  990. 
neuro   -   muscular   dis- 
turbances, 990. 
polyneuritis,  991. 
■ocular  complications,  993. 
motor    nerve    affection 

in,  994. 
optic    nerve    affections 

in,  994. 
sensory  nerve  affections 

in,  994. 
vascular     changes     in, 
995. 
peritoneal    syndrome    in, 

982. 
pulmonary       syndromes, 
985. 

bronchitis  in,  986. 
mild  form  of,  986. 
pneumonia  of  apex  in, 

986-987. 
pulmonary  apoplexy  in, 
987. 
suprarenal      insufficiency 
in  acute  and  subacute 
form,  978,  980. 
urinary  syndromes,  988. 
albuminuria  in,  988. 
htemoglobinuric     fever 
in,  early  bilious,  989. 
temperature  curve  in,  962. 
apyrexia  between  attacks 

in,  967,  968. 
irregular  fever  in,  967. 
isolated  attacks  in,  965. 
occurrence  of  attacks  in, 

967. 
quotidian        intermittent 

fever  in,  965. 
remittent  continued  fever 

in,  962. 
tertian  attacks  in,  965. 
Malaria,  recurrent  fever  associated 

with,  1017. 
Malaria,  secondary    paludisni    of, 
1005. 
ague  fit  in,  1006. 

temperature  in,  1007. 
clinical  study  of,  950. 
clinical  syndromes  in,  1011. 
anaemia  in,  1011. 


Malaria,  secondary    paludism   of, 
clinical  syndromes  in,    bili- 
ous   hiemoglobiuuric    fever 
in,  1011.  attack  of,  1013. 
blood  in,  1014. 
course  of,  1014,  1045. 
icterus  in,  1013. 
occurrence  of,  1013. 
urine  in,  1014. 
nervous  disorders  in,  1012. 
disciplined   febrile  attacks   in, 
1005. 

exhibition  of  parasite   and, 
1005. 
fever  in,  1008. 
irregular,  1011. 
isolated  fits  in,  1010. 
quotidian  intermittent,  10 10 
septan  type  of,  1010. 
tertian  intermittent,  1008. 
Malaria,  treatment  of,  1035. 

in   primary   paludism   in   first 
invasion,  1036. 
mode    of   administration   of 
qiiinine  in,  1037. 
by  ingestion.  1037. 
by  intramuscular  and  sub- 
cutaneous injections 
1038. 
choice  of  solutions  in, 

1038. 
technique    of   injection 
in, 1039. 
time    of    administration    of 
quinine  in,  1041. 
'\i\  primary  paludism  in  second 
attacks,  1043,  1049. 
treatment    of    intervals     in 
1047. 

repair  of  Vjody  in,  1048. 
suspension  of  quinine  in , 
1047. 
treatment    of    relapses    in, 
1043. 

in  quotidian  fever,  1046. 
in     remittent     continued 

fever,  1044. 
in  low  fever,  1044. 
in  pernicious  attacks,  1044. 
in  severe  attack,  1044. 
in  secondary  paludism,  1049. 
treatment    of    ague   fits   in, 
1049. 

administration  of  quinine 
in,  by  ingestion,   1050. 
by    intramuscular    and 
subcutaneous     injec- 
tion, 1050. 


1082 


INDEX 


Malaria,  treatment  of,  in  second- 
ary paludism,  trcMtnieiit  of 
intervals  in,    1051. 
Carducci's      method      of, 

1051. 
Italian  sterilizing  methoil 

of,  1052. 
Job's  method  of,  1051. 
Ravaut's    method  of,  by 
addition    of  cocadylate 
of  soda  and  adrenaline, 
1052. 
typhoid    fever    associated    with, 

20,  102,273,  1010. 
tvphoid  disguise  o*",  232. 
Malarial  dysentery,  311,  469,  1010. 
Malarial  fever,  differentiated  from 

typhus,  409. 
Malignant  hypertoxic  sjqjhilis,  104. 
syphilides,  645. 
svphilis,  579. 
Malta  fever,  101,  232. 
Malvv,  M.,  692. 
Manohurian  War,  173,  700. 
Manifestations,  visceral,  046. 
Manson,      solutions      for      venous 
transfusion  in  cholera,  407. 
treatment  of  cholera,  404. 
Manure,   human,   surface   disposal 

of,  239. 
Marie,    P.    L.,   case   of  abdomino- 
thoracic   form  of   local  tet- 
anus, Sll. 
Marine  salt,  effect  of,  on  cholera 

vibrio,  434. 
Marne,  tetanic  belts  of,  829. 
Married  women  and  svphilis,  520, 

521. 
Marseilles,  epidemics  at,  242,  254, 

28S. 
Masked  paludism,  962. 
Maternal  heredity,  52S. 

infection  and  pregnancv  in  syph- 
ilis, 528,  529. 
Mauriac,  504. 

Mauriac's  neuralgic  herpes,  558. 
Measles,    differentiated    from    ty- 
phus, 469. 
typhoid  fever  and,  17. 
Meat,  contagious  character  of,  259. 

paratyphoid  Ijacilli  in,  258. 
Medical  inspection  in  syphilis,  671, 
672. 
and  numition  works,  504. 
of  mol)ilised  workmen,  672,  073- 
Medicamental  erythemas,  575. 
Medicine,  Academy  of,  535,  69S. 
700. 


Mediterranean    dengue,     co-exist- 
ence of,  in  malaria,  953. 
Mediterranean  fever,  101. 
Meistcr,  Lucius  and  Briining,  013, 

615. 
Melancholia  in  malaria,  992. 
Melaniferous  leucocytes  in  blood  in 

malaria,  1033. 
Meltzer,  S.  J.,  on  injections  of  mag- 
nesium sulphate  in  tetanus, 
894. 
Men.     fretiucncy     of     syphilis     in 

young,  522. 
Meningeal  form  of  typhoid  fever  in 
infants,  \'^^. 
symptoms  in  typhoid  fever,  64. 
type,    convulsive,    of    pernicious 
attacdv    in    second    phase   of 
l^rimarv    paludism    in    ma- 
laria, 1000. 
Meningitis,  1,  64. 
Inisal,  586. 
l)asilar,  633. 
(•eret)ro-s[)inal,  469-470. 

differentiated  fi'oni  paraplegic 

form  of  local  tetanus.  809. 
manifestations     of,      differen- 
tiated from  cephalic  tetanus 
with  ophthalmoplegia,  738. 
spinal,  586. 

symptoms  simulating,  104. 
treatment,  647. 
Meningo-myeletis,  580. 
Meningo-typhoid,  9. 
Menstruation,  cholera  and,  396. 
Mental  confusion  in  malaria,  992. 
Mercurial  cachets,  597. 
colitis,  663,  664. 
compounds  in  syphilis,  593. . 
inunction,  600. 
iodides,  593. 

medication,  endermic,  594. 
by  ingestion,  594. 
iiitranuiscular    and    intraven- 
ous, 594,  600,  602,  608,  609. 
per  rectum,  594,  599. 
stomatitis,  583. 
svruijs,  594. 

treatment  of  syphilis,  intranuis- 
cular  injections  in,  600. 
))y     injection     of     insoluble 
l)rep'"":itions,  601. 
advantages  of,  (501 . 
cniomel  in,  603,  604. 
grey  oil  in,  603. 
inconvenience  of,  601. 
pain  of,  602. 


INDEX 


1083 


Morcurial  (roatmont  of  syphilis,  in- 
truinuscular  injection  in,  by 
injoetion  of  insohihle  pre- 
parations, salicylate  of  mer- 
cury in,  G03. 

yellow  oxide    of   mercury 
in.  603. 
by     injections     of     soluble 
preparations,  604. 
advantages  and  disadvan- 
tages of,  005. 
benzoate   of   mercury   in, 

C06. 
biniodide  of  mercury  in, 

006. 
cyanide  of  mercury  in,  007. 
neutral  salicylate  of  mer- 
cury in,  607. 
oxvcvanide  of  mercury  in, 

(307. 
technique  of,  007. 
intravenous  administration  of, 
008. 
advantages  of,  107. 
cyanide  of  mercury  in,  008. 
objections  to,  009. 
technique  of,  611. 
value  of,  010. 
per  rectum,  599. 
with  arsenic,  088. 
Mercury  in  syphilis,  591,  593. 
and  arsenobenzol,  034,  035. 
and  arsenic,  association  of,  638, 
039,  040,  042,  643. 
JVIerieux,    mixture    of    antitetanic 
serum    and    sub-gallate    of 
bismuth    in    local    treat- 
ment  of  wound   for  pre- 
vention of  tetanus,  849. 
Merozoite,  941. 
iVIetchnikoff,  089. 
Meteorism,  30. 
Methylene  blue,  045. 
Microbial  prophylaxis  in  typhoid, 

227,  234  et  seq. 
Micro-organisms,     hostile     in     ty- 
phoid, 176. 
pathogenic,  various,  117. 
Milian,  632. 
Miliary  syphilides,  578,  645. 

tuberculosis,  100. 
Milk,  a  cause  of  contagion  in  ty- 
phoid, 217,  238,  289. 
a  double  danger,  238. 
as  source  of  dysentery  infection, 

353. 
transmission    of    cholera    vibrio 
by,  430. 


Milk,  paratyphoid  infection  in,  261. 
Milk  diet  in  typhoid  fever,  128. 
Millard,  580. 
Mixed  chancre,  501. 
heredity  and,  528. 
Moisture,  effect  of,  on  survival  of 

cholera  vibrio,  428. 
Mono-articular  arthritis,  75. 
Monod,    Ch.,    case    of    tetanus  of 
right  upper  extremity,  752. 
Mononucleosis    in    blood    in    ma- 
laria, 1033. 
Monoplegic  form  of  local  tetanus, 
783. 
diagnosis  of.  i)ositive',  790. 

bacteriological       examination 
for  bacillus  in,  790-797. 
differential  diagnosi'^  of,  797. 
from  acute  strychnine  poison- 
ing, 802. 
from  contractures  or  pseudo- 
contractures     following    le- 
sions, 799. 
from   contractures   of  tetany, 
800. 
Chvostek's  sign  in,  801. 
fdrcil)le  extension  and  flex- 
ion of  lower  limbs  in,  802. 
hyperexcitability  of  muscles 
and  nerves  to  galvanism 
in,  802. 
Trousseau's  sign  in,  801. 
Weiss's  sign  in,  801. 
from    excitation    or    irritation 
of  motor  and  mixed  nerves 
due  to  lesions,  798. 
from   hysterical   contractures, 

803. 
from    incomplete    hemiplegia, 

798. 
from  spasmodic  monoplegia  of 
cerebral    or   medullary    ori- 
gin, 798. 
period  of  acme  in,  790. 
blood  in,  795. 

cerebro-spinal  fluid  in,  795. 
contractures  in,  790,  791. 
clonic  movements  in,  791. 
generalized  tonic,  form  (ri- 
gidity of),  791-793. 
general  indications  in,  793. 
facial  aspect  in,  794. 
hypersensitiveness  in,  794. 
pulse  in,  794. 
respiration  in,  794. 
iu"ine  in,  794. 
pain  in,  790. 
reflexes  in,  795. 


1084 


INDEX 


JVIonoplogie  form  of  local  tetanus, 
period  of  lu-nio  in,  suimuary 
of,  795. 
period  of  incubation  in,  783. 
in  early  or  precocious  tetanus, 

783." 
in  late-api)earinj?  tetanus,  784. 
due  to  surgical  traumatism, 

784,  785. 
explanation  of,  784-7S5. 
period  of  onset  in,  785. 

general  symptoms  in,  78S. 
exaggeration  of    reflexes  in, 

789. 
facial  expression  in,  789. 
temperature  in,  789. 
local  signs  in,  786. 
cramps  in,  787. 
pain  in,  786. 
skin  in,  786. 
spasms  in,  78G-787. 
stiffness  in,  788. 
summary  of  symptoms  in,  790. 
Morbidity,  venereal,  503. 
Moreschi   and  Marcora,  on  intra- 
venous   injection    of    anti- 
cholera  vaccine.  453. 
Morphia  in  tetanus,  889. 
Mortality,  syphilitic,  525,  526. 
Motor  troubles  in  typhoid  fever,  G3. 
Mouneyrat,  612,  636. 
Mouth,  mucous  membranes  of,  in 
secondary  tetanus,  582. 
treatment  of,  in  typhoid  fever, 

124. 
washes,  667. 
Mucous  membranes,  lesions  of,  in 
syphilis,  582. 
diseases  with  which  they  may 
be  confused,  583. 
plaques,  520,  564,  565,  582,  583, 
619,  620. 
Multiple  chancres,  542. 
Munition    workers    and    sj'philis, 
504,  522,  523. 
treatment  of,  650. 
hospital  treatment  of,  674. 
s\ipervisioii  of,  681. 
work  and  contagion  of,  517. 
Muscles  and  bones,  lesions  of,  648, 

649. 
Muscular  rupture,  74. 
system  in  typhoid,' 74. 
twitchings  in  typhoid,  60. 
Myelitis,  typhoid,  64. 
.Myocarditis  and  the  Great  War,  21. 
complicating     typhus     exanthe- 
maticus,  404. 


Myocarditis  in  typhoid.  41. 

inadvisability  of  vaccination  in, 
275. 
Myositis,  typhoid,  74. 

Nails,  lesions  of,  in  syphilis,  582. 
Nasal  fossie,  importance  of  clean- 
liness, 125.  , 
symptoms  i'.i  typhoid  fever,  38. 
National  peril,  syphilis,  531. 
Necrosis  of  the  larynx,  in  tvphoid, 

3S. 
Needle    for    injection    in    syphilis, 
653,  655. 
steel,  653. 
Negroes,   susceptibil'ty  of,   to   ty- 
phoid fever,  16S. 
Neosalvarsan,  615.  {See  also  Novar- 

senobenzol.) 
Nephritis  in  syphilis,  588. 
secondary  syphilitic,  588. 

treatment  of,  648. 
in  tvphoid,  69. 
acute,  104. 
Nerve,    affection    of    auditory,    in 
syphilis,  633. 
filament,  injury  of,  662. 
Nervous  accidents  in  cholera,  393. 
affections  in  syphilis,  585. 
complications  in  typhoid   fever, 

147. 
disorders  in  bacillary  dysenterv, 
304. 
in  secondarv  paludism  in  ma- 
laria, 1012. 
in    second    phase    of    primary 
paludism  in  malaria,  989. 
focal  symptoms  in,  991. 
mental  disorders  in,  992. 
convulsions,  992. 
melancholia,  992. 
mental  confusion,  992. 
psychosis,  993. 
neuralgia,  990. 
neuro  -  muscular     disturb- 
ances, 990. 
polyneuritis,  991. 
opotherapy  in  tetanus,  884. 
symptoms  in  paratyphoid  fevers, 
83. 
in  typhoid  fever,  58  et  seq. 
meningeal     syndromes     of, 

64. 
motor  disturbances  of,  63. 
psychical    disturbances    of, 

60. 
sensory  disturbances  of,  62. 
typhoid  states  in,  59. 


INDEX 


1085 


Nervous  system,  in  typhoid  fever, 
complications  affectinj?,  90. 
Neuralgia  in  malaria,  990. 

intercostal,  in  syphilis,  633. 
Neuritis,  optic,  587,  G33. 

peripheral,  44. 
Neuro-muscular     disturbances     in 

malaria,  990. 
Neuro-relapses,  633,  634. 
Neuro-retinitis,  633. 
Neurotropism  of  arsenobenzol,  634. 
Neutral  salicylate  of  mercury,  607. 
Nicolaier's  bacillus,  821 

biological  properties  of.  823. 
agglutinability  in,  824. 
gas  formation  in,  824 
indol  formation  in,  824. 
vitality  in,  823. 
cultures  of,  822. 

experimental   pathogenic    action 
of,  824. 
inoculation     with     pure     cul- 
tures in,  825. 
inoculation   with   tetaniferous 
pus  or  soil  in,  825. 
halntat  of,  828. 

isolation  and  cultivation  of,  821. 
mobiUty  of,  822. 
morphology  of,  821. 
staining  of,  822. 
Nicolas,  J.,  539. 

Nicolle  and  Blaizot,  serotherapeu- 
tic     treatment     of     typhus 
fever,  473-474. 
Nicolle's  method  of  staining,  559. 
Nitrate  of  silver,  546,  644,  645. 
Nitritoid  crises,  632,  635. 
Nitrous-indol      reaction     test     in 

cholera,  402. 
No.  "102,"  637;    No.  "606,"  613, 
6.37;    No.  "914,"  615;    No. 
"1116,"  636. 
Nocard,     experimental     investiga- 
tions   of,    on    prophylactic 
action  of  antitetanic  serum, 
in  animals,  856. 
Non- venereal  contaminations,  517. 
Non-paralytic    cephalic     tetanus, 
709. 
dysphagic,  710. 
hydrophobic,  711. 
pure,  711. 
simple,  710. 
varieties  of,  709. 
Novarsenobenzol  in  syphilis,  615, 
638,  642. 
and  nervous  system,  632. 
deaths  from,  632. 


Novarsenobenzol    In  syphilis,  de- 
scription of,  615,  616. 
distilled    water    and,    616,    617, 

618. 
dose  of,  625,  626,  627,  628. 
effects  of,  on  syphilitic  manifes- 
tations, 619. 
on  cutaneous  lesions,  670. 
on  general  condition,  621. 
on  headache,  620. 
on  hemiplegia,  620. 
on  iritis  and  irido-choroiditis, 

621. 
on  mucous  plaques,  619. 
on  syphilitic  chancre,  619. 
injections  of,  642,  644,  645. 
after  effects  of,  628,  629,  630. 
intramuscular,  619. 
periodicity  of,  628. 
serious  accidents  in  treatment 
with,  631. 
acute  incephalitis,  632. 
albuminuria,  635. 
cardiac  disturbance,  6.35. 
cutaneous  eruptions,  635. 
gastro-intestinal     disorders, 

635. 
icterus,  133. 
nervous  disorders,  632. 
neuro-relapses,  632. 
vehicle  for,  616,  617. 
solution,  654,  655. 
Noxious  influence  of  syphilis,  528, 

529. 
Nuclear  theory  of  cephalic  tetanus 
with  ophthalmoplegia,   735. 

Ocular     complications    in     second 
phase  of  primary  paludism 
in  malaria,  993. 
ojitic  nerve  affections  in,  994. 
motor  nerve  affections  in,  994. 
sensorv  nerve  affections  in,  994. 
iritis,  993. 
keratitis,  993. 

secretory  disturbances,  994. 
vascular  changes  in,  995. 
chorio-retinitis,  995. 
conjestion  of  the  retina,  995. 
conjunctival  haemorrhages, 

995. 
exudations,  995. 
iritis,  995. 
keratitis,  995. 
retinal  hsemorrhages,  995. 
uveitis,  995. 
Oculo-motor,      optic      and     facial 
nerves,  lesions  of,  633. 


1086 


INDEX 


Oculo-motor  paralysis  in  secondary 

syphilis,  5<S6. 
CEdema  and  infiltration  precodinf^ 

tetanus,  921. 
Oily  substance  of  biniodide  of  mer- 
cury, 606. 
Ointment,  calomel,  6.S9. 
Opacity-meter,  the,  269. 
Operative    accidents    in    syphilis, 

661. 
Ophthalmoplef?ia,  cephalic  tetanus 

with,    729,    732.       See    also 

Cephalic  tetanus  with   oph- 

thalmoplefiia; 
summary  of,  916r- 
false,  737. 

in  cephalic  tetanus  with  paraly- 
sis of  the  hyperjilossal,  743. 
Opium  in  dysentery,  329. 
Opsonic    index,    determination    of 

the,  121. 
Optic  neuritis,  587,  633. 
Optical  lesions,  5S6. 
Oran  expedition,  cholera  in,  410. 
Organs,     excoriations     of    genital, 

562. 
gangrene  of,  557,  562,  563. 
Oscillations,  ascending,  in  t^-phoid, 

5,  7. 
Osseous  system,  the,  75. 
Osteo-periostitis,  75. 
Otitis  media,  suppurative,  66. 
Overwork  a  predisposing  cause  of 

typhoid  infection,  173. 
Oxycyanide  of  mercury,  607. 
Oxygen,     destruction     of    tetanus 

bacillus  by,  847,  925. 
destruction  of  tetanus  toxin  bv, 

847. 
in  treatment  of  wounds  against 

tetanus,  847. 
Oysters  a  cause  of  typhoid  fever, 

209,  239,  261. 
paratyphoid  infection  in,  261. 
transmission  of  cholera  vibrio  by, 

435. 

Palate,  soft,  lesions  of,  in  svphilis, 

541,  584. 
Pallid  cholera,  388. 
l^almar  psoriasis,  577. 
I^ilpitations,  635. 
Paludism,  defaced,  961. 

masked,  962. 
T'aludism,  primary,  951. 

tlinical  study  of,  949. 

(iiHt   invasion   in   syndromes   of, 
951. 


Paludism, primary, first  invasion  in, 

syndrones  of,  attenuated  form 

of  invasion,   fel)rile  malaise 

and  fatigue,  957. 

continued    fever    of    typhoid 

character  in,  954. 
differentiation    of,     from     ty- 
phoid fever,  957. 
febrile  gastric  derangement  in, 
951. 
diagnosis  in,  953,  954. 
general    symptoms   in,    951. 
pulse  in,  953. 
temperature  in,  953. 
general  symptoms  of,  954. 
pulse  in,  955. 
quotidian    intermittent    fever 

in,  958. 
temperature  in,  955. 
second  attacks  or  relapse  in,  960. 
defaced  paludism  in,  1002. 
masked  paludism  in,  1003. 
pernicious  attacks  in,  997. 
etiology  of,  997. 
forms  of,  998. 
in  algid  form,  1001, 

characteristic  appearance 

of  patient  in,  1001. 
initial  symptoms  in,  1001. 
secondary  alimentary  dis- 
turbances in,  1002. 
in  cerebral  form,  999. 

apoplectic,  isolation  type, 
999. 
aphasia  in,  1000. 
hemiplegia  in,  1000. 
convulsive  meningeal 

type,  1000. 
occurrence  of,  998. 
syndromes    of    visceral    local- 
isations in,  968. 
anoemic  syndromes,  969. 
haemorrhagic  anaemic,  971 
splenomelalgia      aniemia, 

972. 
typical  form  of,  969. 
with  hydrtemia,  970. 
with  icterus,  972. 
auditory  disturbances,  997. 
cachectic  syndrome,   acute, 
983. 

anaemia  in,  983. 
digestive  disturbances  in, 

984. 
])rognosis  of,  i)85. 
cardio-vascular   syndromes, 
987. 
cry  thromelalgia  in,  988. 


INDEX 


1087 


Piiludidm.primany,  second  attacks 
or  relap.se  in,  syndromes 
of  visceral  localisations 
in.  cardio-vaseular  syn- 
dromes, Raynaud's  disease 
in,  9S7. 
symmetrical  gangrene  in, 

987. 
visceral      circulation     in, 
disorders  of.  988. 
gastro-hepatic      syndromes, 
974. 
in     gastro-bilious     forms, 

974. 
in  infective  icterus  form, 
976. 
intestinal  syndrome,  9S0. 
laryngeal  complicatio!is,  9^ ). 
■nervous  manifestations,  9.S9. 
focal  symptoms  in,  991. 
mental  disorders  in,  992. 
convulsions,  992. 
melancholia,  992. 
mental  confusion,  992. 
psychosis,  993. 
neuralgia,  990. 
neuro-muscular     disturb- 
ances, 990. 
polyneuritis,  991. 
ocular  complications,  993. 
motor  nerve  affection  in, 

994. 
optic  nerve  affections  in, 

994. 
sensorv    nerve    affections 

in, 994. 
Avascular  changes  in,  99.5. 
peritoneal  syndrome  in,  9S2. 
pulmonary     svndromes    in, 
985. 

bronchitis     with     pleuro- 
pulmonary     congestion 
in.  98(5. 
mild  form  of,  98G. 
l)neunionia     of    apex    in, 

986-987. 
pulmoiuuy    apoplexv    in, 
987. 
suprarenal      efficiency      in, 
acute      and      subacute 
form  of,  978. 
c-lioleriform     attacks     in, 

979. 
duration  of  symptoms  in, 
979. 
onset  of,  978. 
gradual  form  of,  980. 


Paludism.  second  attacks  or  relap.se 
in,  syndromes  of  visceral 
localisations  in  suprarenal 
eflfioiency  in,  urinary  syn- 
dromes, 988. 
albuminuria  in,  9SS. 
haemoglobinuric  fever  in, 
early  bilious,  9S9. 
temperature  curve  in,  962. 
apyrexia    between    attacka 

in,  987,  968. 
irregular  fever  in,  987. 
isolated  attacks  in,  955. 
occurrence    of    attacks    in, 

967. 
quotidian  intermittent  fever 

in.  965. 
remittent    continued    fever 

in,  962. 
tertian  attacks  in,  965. 
treatment   of,   in  first  invasion, 
1036. 

mode   of   administration   of 
quinine,  1037. 
by  ingestion,  1037. 
by     •intra-muscular     and 
subcutaneous         injec- 
tions, 1038. 
solutions  in,    1038. 
technique    of,  1039. 
time    of    administration    of 
quinine  in,  1041. 
in  second   attacks,   treatment 
of,  1043. 
summary   of   treatment   in, 

1049. 
treatment    of    intervals    in, 
1047. 

repair  of. body  in,  1048. 
suspension  of  quinine  in, 
1047. 
treatment    of    relapses    in, 
1043. 

in  quotidian  fever,  1046. 
in     remittent     continued 
fever,  1044. 
in  low  fever,  1044. 
in    pernicious    attacks, 

1044. 
in  severe  attack,  1044. 
Paludism,    secondarv,  of    malaria, 
100.5. 
ague  fit  in,  1006. 

temperature  in,  1007. 
clinical  study  of,  950. 
clinical  syndromes  of,  1011. 
aniemia  in,  1011. 


1088 


INDEX 


Paludism,  sorondiiry,  olinioal  syn- 
dromes of,    bilious    luiMiioglo- 
bitniric  fever  in,  1011. 
attack  of,  1013. 
blood  in,  1014, 
course  of,  1014,  1015. 
icterus  in,  1013. 
occurrence  of,  1013. 
urine  in,  1014. 
nervous  disorders  in,  1012. 
disciplined    febrile     attacks    in, 
1005. 
evolution     of     parasite     and, 
1005. 
fever  in,  1008. 
irregular,  1011. 
isolated  fits  of,  1010. 
quotidian  interniittent,  1010. 
septan  type  of,  1010. 
tertian  intermittent,  1008. 
treatment  of,  1049. 

treatment  of  ague  fits  in,  1049. 
administration    of    quinine 
in,  bj'^  ingestion,  1050. 
by      intramuscular      and 
subcutaneous  injection, 
1050. 
treatment     of     intervals     in, 
1051. 

Carducci's  method  of,  1051. 
Italian  method  of,  1051. 
Job's  method  of,  1051. 
Ravaut's  method  of,  by  ad- 
dition   of    cocadylate    of 
soda  and  adrenaline,  1052 
Pancreas,  in  typhoid,  72. 
I'apatacci  fever,  232. 
I'apular  syphilides,  576. 

with  large  pajiules,  577,  578. 
with  small  papules,  578,  645. 
P;il)ulo-s(iuamous  syphilides,  578. 
Papyraceous  induration,  541. 
I'aralysis,   facial,  in  syphilis,   58G, 
646. 
tetanus  with,  712. 

age  and  sex  in  occurrence  of, 

715. 
antiluetic  injection  of  wound 

in,  728. 
bacteriology  of,  726. 
characteristics  of,  712. 
clinical  pictine  in,  715. 
diagnosis  of,  727. 

from  tic  douloureux,  727. 
from  traumatic  spasms,  727. 
in  infectious  wounsd  of  face, 

728. 
'  ■  ''nilatoral  symptoms,  727. 


Paralysis     facial,    tetanus     with, 
duration  of,  726. 
etiology  and  frequency  of,  714. 
facial  paralysis  in,  721. 
clinical  characters  in,  721. 
in     complete     peripheral 

facial  paralysis,  722. 
in  lower  facial  type,  72'lj 
in  superior  facial  type, 723. 
in  total  facial  type,  723. 
co!nmencement  of,  721. 
development  of,  724. 
diagnosis  of,  724. 
pathogenesis  of,  725. 
prognosis  in,  724. 
situation  of,  721. 
fever  in,  725. 
history  of,  713. 
incubation  in,  718. 
individual  signs  in,  717. 
muscular  contractions  in,  719. 
degree  of,  719. 
extension  of,  720.  / 

in  paralysed  muscles,  719. 
in  side  not  paralysed,  720. 
prognosis  of,  726. 
situation  of  wound  In,  717, 
trismus  in,  718. 
Paralysis  in  typhoid  fever,  23,  64. 
ocular,    cephalic    tetanus    with. 
{See  Cephalic  tetanus  with 
ophthalmoplegia.) 
of  cranial  centers,  633. 
of  oculo-motor  nerves,  586. 
Paraplegic  form  of  local  tetanus, 
805. 
diagnosis  of,  809. 
differential    diagnosis    of,    from 
cerebro-spinal      meningitis, 
809. 
symptomatology  of,  805. 
in  inferior  type,  806. 

contractures    of    limbs    in, 

806. 
muscular    rigidity    of     ab- 
dominal wall  in.  806. 
in  superior  type,  807. 
pain  in,  807. 
reflexes  in,  808. 
summary  of,  808. 
temperature  in,  808. 
types  of.  805. 
Paratyphoid,  ambulatory,   11,  93, 

180. 
Paratyphoid  bacilli,  182. 

differentiated  from  typhoid 
bacillus  and  Bacillus  coli, 
113,  114-115. 


INDEX 


1089 


Paratyphoid  liacilli.  difforpntintcd 

from  typhoid  l)acilliund  Bacillus 

coli,  a{?«lutinal)ility  in,  116. 

iiacillus   fuecalis   alkaligenes 

and.  117. 
intermediate  haoilli  in.  117. 

moans  of  entrance  of,  250. 

pi'ohablo  carriers  of,  236. 

Widal's  serum  test  in,  IIS. 
Paratyphoid  fevers,  A  and  B,  80 
d  se([. 
abdominal  pain  and  tenderness 

in,  S2. 
antipyretic  measures  In,  133. 
atteimated  forms  of,  92. 
bladder  disturbances  in,  89. 
Imocal  exanthem  in,  83. 
cardiac  disorders  in,  84. 
oholeriform  symptoms  of,  94. 
clinical  characters  of,  SO. 
clinical  diagnosis  of,  90  ei  seq. 
complications  of,  87. 
contagion  in,  by  food,  257. 
convalescence  in,  87. 
course  in,  80. 

diagnosis    by   laboratory    meth- 
ods, 107  et  neq. 
diet  in,  128. 

ditforentiated  from  typhoid,  93. 
difficulty  of  diagnosis,  in  97. 
<>|)idemics  of,  258,  201. 
etiology  of,  250. 

animals  as  carriers  in,  257. 

drinking  water  in,  258. 

fa'cal  matter  in,  250. 

food  in,  257. 

general  consideration  of,  253. 

human  carriers  in,  250. 

meat  in,  258. 

milk  in,  261. 

oysters  in,  261. 
gastro-intostinal  form  of,  93. 
Ingiene  of  genito-urinarv  organs 

in,  127. 
hygiene  of  patient  in,  123. 
hygiene  of  skin  in,  125. 
incubation  period  of,  81.  255. 
intestinal  haemorrhage  in.  88. 
intestinal  perforation  in,  89. 
kidney  disorders  in,  89. 
lenticular  rose  spots  in,  76,  83, 

93. 
mild  form  of,  92. 
nervous  symptoms  in,  S3, 
occurrence  of,  2.53. 
onset  of,  82. 
peritouitis  in,  89. 


Paratyphoid    fevers,    A    and    B, 
phlebitis  in,  89. 
prophylaxis  of,  253  et  aeq.,  261 

et  seq. 
pulmomary  complications  in,  89. 
pulmonary  signs  in,  84. 
l)ulse  in,  86. 

reaction   of   fixation   of   comple- 
ment in  test  for,  121. 
"regional  influences,"  in,  255. 
relapses  in,  87. 
resemblance  of.  to  cholera,  94. 

to  other  intestinal  forms,  92. 
resemblance    of    symptoms    and 
complications     of,     to     ty- 
phoid, 97. 
statistics  of,  90,  91. 
symptoms  of,   resembling  other 

intestinal  diseases.  73. 
temperature  in,  56,  82,  85. 
tetany  in,  90. 
toilet  of  mouth  and  nasal  fossie 

in.  124. 
treatment  of,  123  et  seq. 
ubiciuity  of,  254. 
urine  in,  84. 

value   of   blood  examination   in 
diagnosis  of,  92. 
Paratyphoifl  infections,  257. 
Parietal  arteritis.  45. 
Paris,  epidemic  of  cholera  at,  434. 
typhoid  fever  mortality  in,  171. 
typhus  epidemic  at,  393-394. 
water-supply  of,  212. 
Parotitis,  72. 

Parthenogenesis  of  gametes,  942. 
Pai-tial  tetanus.    Sec  Local  tetanus. 
Pasteurian  method  of  vaccination, 

263. 
Paternal  heredity.  528. 
Patient's  antecedents  and  second- 
ary syphilis.  547. 
Pautrier,"50"8.  534. 
Pautrier's  report  on  syphilis,  534. 
Pediculus    Capitis,    P.     pubis,    P. 
vcstiincnti,    in    transmission 
of  typhus,  492. 
Pe<h'ciiliis  vcstiniciiti,  492.  499. 
Penetration,  intraparietal,  661. 
Penis,  epithelioma  of.  557. 
Perforation,  intestinal,  33,  145. 

in  paratyphoid,  89. 
Perforative  peritonitis,  34. 
Pericarditis.  41. 

Periodicity  of  injections  of  novar- 
senobenzol  in  syphilis,  628. 
Perionyxis,  582. 


1090 


INDEX 


Periostitis,  chronir,  75. 
circumscribed,  75. 
in  amftM)ic  dysentery,  307. 
in  dysentery,  .304. 
Peritoneal    symptoms    in    second 
phase  of  primary  paludism 
in  malaria,  982. 
Peritoneum,  68. 

Peritonitis    in    typhoid    fever,    68, 
14.5. 
perforative,  34. 
without  perforation,  89. 
Periungual  syphilides,  582. 
I'erivenous    cellular    tissue,    pene- 
tration of  fluid  into,  in  sy- 
philis, 662. 
Permanganate  of  potash,  546. 
Peinicious     anaemia,     progressive, 
971. 
attacks    in    malaria    in    second 
phase    of    pnr:i;u-y    palu- 
dism, 961,  997. 
algid  form  in,  1001. 

characteristic  appearance  of 

patient  in,  1001. 
initial  symptoms  in,  1001. 
secondary    alimentary    dis- 
turbances in,  1002. 
cereliral  form  in,  999. 
apoplectic, isolation  type, 999. 
aphasia  in,  1000. 
hemiplegia  in,  1000. 
convulsive  meningeal  tvpe, 
1000. 
etiologv  of,  997. 
ff)rms  of,  998. 
occurrence  of,  998. 
Peroxide  of  hydrogen,  546. 
J^ensonal    precautions    in    syphilis, 

688,  689. 
Perspiration,  76. 

Peycr's   patches,    tyhpoid   bacillus 
in.  176,  177. 
ulceration  of,  frequent  in  para- 
typhoid fevers  A  and  B,  81 
{note) . 
Pharmaceutical  Formulary  for  Mil- 
itary Hospitals,  599. 
Pharyngeal  ulcers,  29. 
Pharynx,  lesions  of,  584. 
Phelip  and  Policard,  case  of  sub- 
acute  and   benign   tetanus, 
799. 
Phleljitis,     in     paratyphoid,     fre- 
quency of,  89. 
in  syphilis,  588. 
in  typhoid,  43. 
Phlegmasia  alba  dolens,  43. 


Photophobia  in  syphilis,  587. 
Phrenicotomy,   bilateral,   in  treat- 
ment of  tetanus,  905. 
Physiological    seruin    in    syphilis, 
644. 
and  novarsenobenzol,  618. 
Physiopathic  disturbances,  990. 
Pigmentary  syphilide,  579,  580. 
Pityriasis  rosea,  Gibert's,  575,  576. 
Plaques,  depapillated,  583. 
giant,  584. 
mucous,  520,  564,  565,  582,  583, 

619, 620. 
of  Bazin  and  Legendre,  576,  577. 
Plasinodiuni  falciparum  in  blood  in 
malaria,  939,  1025,  1029. 
gametes  of,  1030.  i 

sehizont  of,  1029.  ' 

Plasmodium    m.alarice  in   blood    in 
malaria,  989,  1025. 
amoeboid  bodies  of,  1031. 
gametocytes  of,  1033. 
rosette  bodies  of,  1031. 
schizonts  of,  1031. 
Plasmodium  vivax  in  blood  in  ma- 
laria, 939,  1025.  ^ 
amoeboid  body  of,  1027. 
blood  corpuscles  in,  1025. 
gametes     (or    gametocytes)     of, 
1027.  ^ 
parasite  itself  in,  1025. 
sehizont  of,  1025. 
Pleura,  40  et  seq.,  14. 
Pleurisy,  hsemorrhagic,  40. 

in  typhoid,  40,  147. 
Pleuro- typhoid,  9,  40. 
Pneumonia,    apical,    differentiated 
from  typhus,  470. 
in  malaria,  986-987. 
in  cholera,  393. 
in  tvphoid  fever,  18,  39. 
lobar,  103. 
Pneumo-typhoid,  8,  39. 
Poisoning,  differential  diagnosis  of 

cholera  from  forms  of,  398. 
Police  supervision  of  syphilis,  699. 
Polio-encephalitis,  acute,  63. 
Polyclinics,  690,  691. 
Polyneuritics  in  malaria,  991. 

in  syphilis,  633. 
Polyvalent  bacillary  vaccine  steril- 
ised by  ether,  151. 
Post-hospital  treatment  and  .super- 
vision, 679,  680. 
Post-vaccinal  fever,  271. 
Potassium,    bromide    in    tetanus, 
889. 


INDEX 


1091 


Pozzi,   case  of  paraplegic  form  of 
local  tetanus,  805. 
case  of  tetanus  of  left  lower  ex- 
tremity, early,  749,  7<S2. 
Precautionary  measures  in  syphilis, 
670. 
after  cyanide  of  mercury  injec- 
tions, 663,  664. 
after  novarsenobenzol  injections, 

664,  665. 
circulars     on,     670,     672,     673, 

679,680,681,692. 
in  examination  of  patients,  540. 
Prechancrous  herpes,  558. 
Precocious  tetanus,  incubation  per- 
iod of,  783. 
I'regnancy,  cholera  and,  396. 

maternal    infection    of    syphilis 

and,  528,  5:^9. 
typhoid  fever,  and,  16. 
Premonitory  diarrhoea  in  cholera, 
380. 
treatment  of,  404.      , 
Pressure  forceps,  654,  655. 
Prolonged  typhoid  fever,  10. 
Prostitutes  and  chancre,  695. 

and    treatment,    694,    695,    696, 

697,  700. 
clandestine,  and  public  register, 

702. 
registered,  and  supervision,  701, 
702,  703. 
Prostration  and  its  causes,  59. 
Proto-iodide   of   mercury    cachets, 

597. 
Pruriginous  cutaneous  lesions,  584. 
P.seudo-chancre   and  arsenobenzol, 

566,  5(J7. 
Pseudo-tetanic         symptoms        in 

wounded,  798 
Psychical  disturbances  in  typhoid 

fever,  60. 
Psj^cliosis  in  malaria,  993. 
Ptosis,  hysterical,  740. 
I'uerperal  fever,  simulatory  symp- 
toms of,  104. 
Pulmonary  comphcations  in  chol- 
era, 393. 

broncho-pneumonia,  393. 
pneumonia,  393. 
in  paratyphoid  fever,  89. 
in  typhoid  fever,  146,  183. 
diseases,  typhoid  fever  and,  19. 
gangrene,  40. 
oedema,  39. 
signs  in  paratyphoid,  84. 


Pulmonary  syndromes   in    second 
phase  of  primary  paludism 
in  malaria,  985. 
bronchitis  with  pleuro-pulmo- 

nary  congestion  in  986. 
mild  form  of,  986. 
pneumonia   of   apex   in,    986- 

987. 
pulmonary  apoplexy  in,  987. 
Pulse,  and  temperature  in  typhoid 
and  paratyphoid,  49,  86,  89. 
in  typhoid  fever,  49. 
dici'otic,  51. 

relation  of  temperature  to,  57. 
irregularities  of,  51. 
relations    between    temperature 
and,  57. 
Puncture,  lumbar,  6.33,  634. 
Pupillary  disorders  in  cephalic  te- 
tanus complicated  by  oph- 
thalmoplegia, 734. 
Purgatives,   saline,  in   cholera  ex- 
amination, 446. 
in  dysentery,  329. 
and  laxatives  in  typhoid,  142. 
Purpura,  78. 
Pustular  syphilides,  679. 
Pyemia,  simulatory  sjmiptoms  of, 

104. 
Pyramidon  in  typhoid   fever,   140 
Pyrethrum    powder,    value    of, 
fly-destruction,  241. 

Quartan  fever  in  malaria,  1008. 
Queyrat,  543. 

Quinine  amaurosis  in  second  phase 
of  primary  paludism,  994. 
deafness,  997. 
in  chronic  dysentery,  332. 
in  haemorrhagic  anfemia,  of  sec- 
ond    attacks     in     primary 
paludism,  971. 
in    treatment    of    malaria,    939, 
941,  1035. 
in   primary  paludism  in   first 
invasion,  1036. 
mode  of  administration  of, 
1037 

by  ingestion,  1037. 
by    intramuscular    and 
subcutaneous     injec- 
tions, 1038. 
choice  of  solutions  in, 

1038. 
technique    of    injection 
of,  1039. 
time    of   administration    of, 
1041. 


1092 


INDEX 


Quinine,  in  treatment  of  malaria, 
in  primary  paludism  in  second 
attacks,  1043. 
summary  of  treatment  in, 

1049. 
suspension  of,  in  intervals, 
1047. 

repair    of    body    during, 
1048. 
use  of,  in  relapses,  1043. 
in  quotidian  fever,  1046. 
in     remittent     continued 
fever,  1044. 
in  low  fever,  1044. 
in    pernicious    attacks, 

1044. 
in  severe  attacks,  1044. 
in  secondary  paludism,  1049. 
in  ague  fits,  1049. 

administration  of  quinine 
in,  by  ingestion,  1050. 
by   intramuscular   and 
subcutaneous    injec- 
tion, 1050. 
in  intervals,  1051. 

Carducci's     method     of, 

1051. 
Italian  sterilizing  method 

of,  1052. 
Job's  method  of,  1051. 
Ravaut's  method  of,  by 
addition  of  cocadylate 
of  soda  and  adrenaline, 
1052. 
in  typhoid  fever,  140,  226. 
with  adrenaline  in  case  of  ma- 
laria with  syndrome  of  acute 
cachexia,  985. 
Quotidian    intermittent    fever    in 
first  phase  of  primary  plaud- 
ism,  958. 
in    second    attacks    of    primary 

paludism,    965. 
in  secondary  paludism  in,    ma- 
laria,  1010. 
quinine,  treatment  of,  1046. 

Race,  compromise  of,  in  syphilis, 
523. 

Racial  susceptibility  to  typhoid 
fever,  170. 

Rauzier  and  Estor,  case  of  late- 
appearing  tetanus  of  right 
lower  extremity,  769,  782. 

Ravaut,  551,  578,  580,  586,  617, 
628,  634,. 6.^9. 
and  Schlikevitch,  640. 


Ravaut's  method  of  quinine  ad- 
ministration in  the  intervals 
in  secondary  paludism  in 
malaria,  1052. 

Raynaud's  disease  in  second  phase 
of  primary  paludism  in  ma- 
laria, 987. 

Reaction,  Herxheimer's,  620,  635. 
Wassermann,  524,  529,  554,  555, 
556,  563,  565,  567,  572,  573, 
581,590,622. 

Reactions,  humoral,  in  typhoid  in- 
fections, lis  et  seq. 

Reagents,  in  typhoid,  72. 

Recrudescences  in  typhoid,  10,  23. 

Rectal  enemata  in  typhoid,  138. 
instillations  in  typhoid,  138. 

Recto-sigmoidoscope  in  dysentery, 
330. 

Rectum,  mercurial  medication  per, 
594,  599. 

Recurrent    fever    associated    with 
malaria,  1017. 
in  typhoid,  232. 

Recurrent  syphilitic  chancre,  567. 

Refrigeration  by  cold  air  in  typhoid 
fever,  38. 

Registered  prostitutes  and  super- 
vision, 700,  701,  702,  703. 

Relapses,  in  typhoid,  23. 

Relapsing  fever,  differentiated 
from  typhus,  469. 

Remittent  continued  fever  in  sec- 
ond    attacks     in     primary 
paludism,  962. 
quinine  treatment  of,  1044. 
in  low  fever,  1044. 
in  pernicious  attacks,  1044. 
algid  form  of,  1045. 
comatose  form  of,  1045. 
in  severe  attack,  1044. 

Remlinger  on  "sign  of  the  tongue" 
in  typhus,  462. 

Renal  typhoid,  69. 

Renault,  Alex,  597. 

Renault's  formula,  597,  598. 

Respiratory  system,  in  typhoid 
fever,  38. 

Rest  zone  contaminations,  698. 

Retarded  congenital  syphilis,  531. 

Retention,  biliary,  587. 

Retintis,  in  syphilis,  587,  633. 

Rheumatism  in  typhoid,  acute  ar- 
ticular, 102. 

Rice-water  vomit  in  cholera,  382. 

Richelot,  case  of  tetanus  in  partial 
and  generalized  forms,  781. 


INDEX 


1093 


Ricord,  544,  548,  557. 

Ricord's  pills,  596. 

Ristitch,  563. 

Risus  sardonicus,  716,  720,  731. 

River    water,    cholera    vibrios   in, 

431-434. 
Rocky    Mountain    spotted    fever 
differentiated  from  typhus 
470. 
Rocliffe,     case     of    tetanus    with 
ptosis    and    diploxia,    729, 
733. 
Rogers,  solution  for  venous  trans- 
fusion in  cholera,  407. 
Rollet,  560,  561. 

Rose,  asthenic  theory  of  origin  of 
aphalic  tetanus   with   oph- 
thalmoplegia, 735. 
Rose  spots,  lenticular,  76,  83,  93. 
Roseola,  521,  573,  574,  639. 
Fournier's  urticarial,  574. 
granular,  macular,  and  papular, 

574. 
recurrent  or  delayed,  574,  575. 
Rosette  bodies,  940. 

of   Plasmodium   malarise,    1031. 
Rousseau,  506. 

Routier,  case  of  abnormal  tetanus 
of  left  upper  extremity,  755. 
case  of  local  tetanus  in  lower  ex- 
tremity, 788. 
case  of  tetanus  of  left  lower  ex- 
tremity, 760,  758. 
case  of  tetanvis  of  right  lower  ex- 
tremity, 756,  758. 
Roux    and    Vaillard,     antitetanic 
serum  produced  by,  821. 
investigations      on      antitetanic 
serum,  853,  854. 
Rubbings,  in  syphilis,  594. 
Rupture,  haemorrhage  and,  74. 
Rural   contamination  in   typhoid, 

206. 
Rural     vs.     urban    susceptibility 

to  typhoid  infection,  170. 
Russia,    epidemic    of    cholera    at, 
414,434. 
epidemic  of  typhus  in,  479. 
vaccination  against   cholera  in, 
450. 
Russo-Japanese  War,  dysentery  in, 
341. 
typhoid  in,  162. 
Russo-Turkish  War,  dysentery  in, 
340. 


tvphoid  in,  161,  207. 
typhus  in,  477,  482. 

Sainton,    procedure    for    carbolic 
acid  treatment  of  tetanus, 
881. 
Salicylarsenate     of     mercury,     in 

syphilis,  612. 
Salicylate  of  mercury,  in  syphilis, 

603. 
Saline    purgatives   in    cholera   ex- 
amination, 446. 
in  dysentery,  429. 
Salivary  glands  in  typhoid,  72. 
Salivation,  in  syphilis,  651. 
Salmonelloses,  257. 
Salol   as    adjuvant   in    antitetanic 
serum  treatment,  871. 
in  syphilis,  667. 
Salvarsan,   613,'  638.         (See   also 
Arsenobenzol.) 
in  antitoxic  treatment  of  tetanus, 
883. 
Saprophytic    organisms    antagon- 
istic   to    dysentery    bacilli, 
351-357. 
Satellite  adenopathy,  544. 
Scabies  in  syphilis,  557,  561,  562. 

in  typhoid,  20. 
Scabous,  chancre,  539. 
Scarlatina  in  typhoid  fever,  17. 
Schaudinn,  549. 
Schizogony,  940. 

retrogressive,  942. 
Schizonts,  939. 

of  Plasmodium  falciparum,  1029. 
malarise,  1031. 
vivax,  1025. 
Schlikevitch  and  Ravaut,  640. 
Sciatica  in   second   phase   of   pri- 
mary paludism,  990. 
Seasons,  role  of,  in  typhoid  infec- 
tion, 165. 
Sea-water,  cholera  vibrios  in,  434- 

436. 
Second  incubation  in  syphilis,  572. 
Secondary  and  tertiary  syphilides, 
557. 
disturbances     in     syphilis     and 

treatment,  643. 
lesions  in  syphilis,  619. 
period  in  syphilis,  572. 
Secondary  syphilis,  572. 
alopecia  in,  581. 
and     patient's     antecedents, 
547. 


1094 


INDEX 


Secondary      syphilis,       cutaneous 
lesions  of,  573. 

pigmentary  syphilide,  579. 
vesicular,  bulbous  and  pus- 
tular syphilides,  579. 
papular  syphilides,  576.' 
syphilitic  plaques,  576. 
with  large  plaques,  577. 
with  small  plaques,  578. 
roseola,  573. 

Gibert's    pityriasis    rosea 

and,  575. 
medica'mental  erythemas 
and,  575. 
general  phenomena  of,  572. 
lesions  of  nails  in,  582. 
lesions  of  mucous  membranes 
in,  582. 

of  cheeks,  583. 
of  mouth,  582. 
of  tongue,  583. 
lesions  of  pharynx  in,  584. 
in  soft  palate,  584. 
in  tonsils,  584. 
nervous  affections  in,  585. 
facial  paralysis,  586. 
headache,  585. 
hemiplegia,  585. 
lymphocytosis    of    cerebro- 
spinal fluid,  586. 
meningo-myelitis,  acute,  586. 
ooulo-motor  paralysis,  586. 
sensory  organs  in,  586. 
deafness  in,  586. 
iritis  in,  586. 
optic  neuritis  in,  587. 
retinitis  in,  587. 
icterus  in,  587. 
nephritis  in,  588. 
phlebitis  in,  588. 
treatment  of,  644. 

local  applications  in,  644. 
for  papular  syphilides  with 

small  papules,  645. 
for    ulcerations    of    skin, 
645. 
special  medicfltion  in,  646. 
for  facial  paralysis,  646. 
for  headache,  646. 
for  hemiplegia,  647. 
for  iritis,  647. 
for  lesions  of  muscles  and 

bones,  648. 
for  nephritis,  648. 
visceral  affections  in,  585. 


Sedatives  in  treatment  of  tetanus, 
887,  889. 
belladonna,  889. 
choral,  889. 
curare,  889. 
ether,  889. 
hyoscamus,  889. 
morphia,  889. 
potassium  bromide,  889. 
Sedentary  services  and  contamina- 
tion in  syphilis,  516. 
Segond's  Pills,  .329-330. 
Senses,  special,  in  typhoid,  65,  66. 
Sensory  affections  and  arsenoben- 
zol,  .586. 
organs   and  secondary  syphilis, 

586. 
troubles  in  typhoid,  62. 
Septan  fever  in  secondary  paludism 

in  malaria,  1010. 
Septicaemia,    fixation    abscess    in, 
141. 
symptoms  simulating,  104. 
strepto-typhoid,  18. 
Septicsemic  character  of  typhoid,  1. 
Serbia,  typhus  in,  478,  482. 
Sereins  and  Houques,  reflex  theory 
of     cephalic     tetanus    with 
ophthalmoplegia,  735. 
case  of  tetanus  complicated  by 
ptosis,  729. 
Sergent's  suprarenal  white  line,  74. 
Sero-diagnosis  of  dysentery,  313. 
Serotherapy  in  dysentery,  325-326. 
Serotherapy   in   treatment   of    te- 
tanus, 852. 
abuse  of  heterogeneous  seruTti? 

in,  864. 
antitetanic  serum  in,  852. 
anaphylaxis  following,  869. 
anti-anaphvlactic   measures 

in,  864-865. 
dosage  in,  870. 
efficacy  of,  865. 
historv  of,  852. 
injeotions  in,  872. 

injections    in    contact  with 

wound  in,  880. 
intra-arterial   injections  in, 

877. 
infra-cerebral  injections  in, 

878. 
intramuscular  injections  in, 

875. 
intra-nervous  injections  in, 

879. 
intravenous    injections    in, 
875. 


INDEX 


1095 


Sorotliorapy  in  treatment  of  tetan- 
us, antitetanic  serum  in,  in- 
jections in,  para-nervous  injec- 
tions in,  880. 

para-radicular  injections  in, 

880. 
sub-arachnoid  injections  in, 

878. 
subcutaneous  injections  in, 

874, 880. 
value  of,  872. 
innocuousness  of,  858 
preparation  of,  853. 
properties  of,  854. 
antitoxic,  854. 
I>rophylactic,  855. 

against  tetanus  infection, 

855. 
against  tetanic  toxin,  855. 
rules  for  injection  of,  867. 
salol  as  adjuvant  in,  871. 
Si'mptoms  due  to  first  injec- 
tion of,  858. 
eruptions,  858. 
fatal,  860. 

serum  sickness,  869. 
symptoms  due  to  re-injection 
of,  861,869. 
immediate,  861,  869. 
late-appearing,  860,  870. 
in  tvphoid,  148. 
in  typhus.  473-474,  488. 
Serum     and    arsenobenzol,     phys- 
iological, 618,  644. 
diagnosis  of  typhoid  fever,  47. 
immunisation  in  dysentery,  375. 
sickness,  869. 

treatment  of  wound  in  cephalic 
tetanus,  728. 
Sexual   relations   in   sj'philis,    667, 

668. 
Shell-fish,  a  cause  of  paratyphoid 
contagion,  261. 
as  a  means  of  indirect  contagion, 
210. 
Shiga,  experiments  of,  on  vaccina- 
tion against  dysentery,  375. 
bacillus   of   dysentery,    differen- 
tial characteristics  of,  322. 
vitality  of,  350. 
Shock,    anaphylactic,   in    adminis- 
tration of  antitetanic  serum, 
767. 
Shoes  and  socks,  good,  precaution 

against  tetanus,  921. 
Silver  staining,  551. 
Simon,  Clement,  654,  702. 


Simple  chancre,  557,  558,  559,  560. 

inoculation  of,  559. 
Simulation,  ulcerations  in  syphilis 

induced  for,  557. 
Sixth  cranial  nerves,  paralysis  of, 

in  cephalic  tetanus,  733. 
Skin,   affections  of,   typhoid  fever 
and,  20. 
hygiene  of,  125. 
in  typhoid  fever,  76. 
ulcerous  lesions  of,  645. 
Soap  as  antiseptic,  689. 
Sodium    persulphate    in    antitoxic 
treatment   of  tetanus,   885, 
926. 
preparation  of,  926. 
Soil  as  source  of  dysentery  infec- 
tion, 353. 
contagion  of,  203,  206,  207. 
Somnolence  in  typhoid  fever,  59. 
Sore  throat  in  syphilis,  521. 
South    African    War,    typhoid    in, 

208. 
Spanish-American    War,     typhoid 
fever  in,  218. 
mortality  in,  161. 
Spasms  in  typhoid,  63. 

traumatic,  of    face,     differentia- 
tion   of,    from    cephalic,  te- 
tanus with  facial  paralysis, 
727. 
Special  senses  in  typhoid  fever,  65. 
Spick,  503. 

Spillmann.  L.,  515,  521. 
Spinal  meningitis,  latent,  634. 
Spinal  nerves,  lesions  of,  633. 
Spirillar  injection,  Vincent's,   585. 
Spirillum  dentium,  553. 
Vincent's,  553. 
ds^sentery,  309. 
Spirochaela  huccnlis,  553. 
refi-riigenfi,  552,  553. 
pallida.     (See    Treponema  palli- 
dum. 
Splanchnic  tetanus,  707.  708. 

clinical  manifestations  of,  708. 
course  and  prognosis  of,  709. 
summary  of,  914. 
Spleen,  enlargement  of,  in  typhoid, 

37.  83,  106. 
Splenomegalic    anfemia   in    second 
attack  in  primary  invasion 
of  malaria,  972. 
Sponging  a  typhoid  fever  patient, 

133. 
Sporogony,  943. 

Spotted   fever.    Rocky    Mountain, 
470-471. 


1096 


INDEX 


St.  Louis  Hospital,  600,  095. 

statistics  of  syphilis  in,   510, 
512. 
Staining  in  blood  examination  of 
malaria,  1019. 
Lavcran's  panchrome  in,  1024, 

1033. 
Senevcts'    borax  -  cosin  -  blue 

stain  in,  1021. 
Triljondeau's  In-eosinate  stain 

in, 1019-1021. 
water  used  in,  precautions  re- 
KardinR,  1()22. 
Ivanjioron's    method  of  test- 
ing in,  1022. 
results  with  ordinary  water 
in, 1023. 
with  deep  staininff,  1024. 
with  faint  stainins;,  1023. 
with   intei'incdiate   stain- 
ing, 1024. 
NicoUe's  method  of,  501. 
silver,  551. 
Sterilisation  of  water,  necessity  of, 

237,  247. 
Stibial  cholera.  .39S. 
Stibico-arKentic  sulphate  of  dioxy- 

diamino-arsenobenzol ,  037. 
Stomatitis  in  syphilis,  051,  007. 

mercurial,  5<S3. 
Stools,    choleraic,    3S1-3,S2,    410- 
417. 
dysenteric,  297,311. 
paratyphoid  infection  in,  250. 
typhoid  bacilli  in,  179. 
Street  dirt,  typhoid  infection  from, 

200. 
Streptococcal  infection  in  typhoid 

fever,  18. 
Strong  bacillus  of  dysentery,  differ- 
ential    characteristics      of, 
322. 
Strychnine  poisoning,  acute,  differ- 
entiated   from    monoplegic 
form  of  local  tetanus,  802. 
Stupor  in  typhoid,  59. 
Sublimate  in  syphilis,  546. 

pills,  590,  597. 
Subnitrate  of  bismuth  in  syphilis, 

643. 
Sudamina,  7S. 
Sulphur  baths,  045. 
Sunday  con.sultations,  090. 
Sunlight,    bactericidal    action    of, 
205,  200,  214. 
effect  of,  on  cholera  vibrio,  431. 
•vitality  of  dysentery  bacilli  in, 
251. 


Suppositories,  594,  599. 

Audry's,  599,  600. 
Suppurative  conditions  complicat- 
ing typhus  exanthematicus, 
465. 
hepatitis,  305. 
Suprarenal  capsules,  73. 
Suprarenal  insufficiency  in  second 
phase  of  primary  paludisin, 
978. 
acute  and  subacute  form  of, 
978. 

choleriform  attacks  in,  979. 
duration  of  symptoms  in, 
979. 

general  condition  in,  978. 
onset  in,  978. 
gradual  form  of,  980. 
in  tiyphoid,  73.  _ 
Surgical  traumatism,  acceleration 
of  development  of  tetanus 
by,  785. 
local    tetanus   caused    by,    late 
appearance  of,  784. 
explanation  of,  784-785. 
incubation  period  in,  784. 
"Sweating     fevers,"     in     typhoid 

cases,  70. 
Sweating  in  paratyphoid  fevers,  83. 
Synaptic  membrane,  895. 
Synochus,  11. 

Syphilide,  acneiform,  lichenoid  and 
miliary,  578,  045. 
pigmentary,  579,  580. 
Syphilides,   bullous,   pustular  and 
ulcerative,  579. 
chancriform,  505. 
characteristics  of  secondary,  573. 
follicular,  578,  645. 
malignant,  645. 
papular,  576. 

with  large  papules,  577,  578. 
with  small  papules,  578,  045. 
papulo-squamous,  578. 
periungual,  582. 
secondary  and  tertiary,  557. 
Syphilis,  a  national  danger,  518. 
and     precautionary     measures, 

009,  070,  082. 
cerebro-meningeal,  585. 
children  contaminated  by,  522. 
civilians  and,  518,  520. 
complement-fixation  test  in,  554. 
congenital,  retarded,  531. 
diminution  of  effectives  by,  523. 
diminution    of  men's  value  in, 

524. 
disastrous  influence  of  war,  532. 


INDEX 


1097 


Syphilis  hygiene  in,  GGG. 
clothiiiR  in,  667. 
drinkins  of  alcohol  in,  667. 
hygiene  of  mouth  in,  667. 
seKual  relations  in,  667. 
suppression  of  tobacco  in,  666. 
in  the  army,  frequency  of,  50.i, 
504,  524. 
leave  and,  513. 
origin  of,  509. 
incubation  period  of,  547. 
influence  of,   on  birth  rate  and 

future  generations,  527. 
isolation  in  contagious,  675. 
malignant,  579. 

malignant   hypertoxic,   and    ty- 
phoid, 104. 
married  women  and,  520,  521. 
numition  workers  and,  504,  522, 

523. 
noxious  influence  of,  528,  529. 
para.site  of,  549. 

pregnancy  and   maternal   infec- 
tion in,  528,  529. 
prophylaxis  in,  669. 

creation  of  centres  for  treat- 
ment of  syphilis,  in,  690. 
for  protection  of  healthy  men, 
682. 

distribution    of    pamphlets 
in,  687. 

lectures  in,  682. 
personal  precautions  in,  6SS. 
hospital  treatment  in,  (»73. 
advice     to     syphilitic     pa- 
tients in,  67S. 

locality    of    liospitalization 

for  syphilitics  in.  ()7(). 

isolation  of  syphilitic  carriei"s 

of  contagious  lesions  in,  670. 

medical  inspection  in,  ()7l. 

post-hospital    treatment    and 

supervision  in,  679. 
supervision  of  prostitution  in, 
694. 
retarded  congenital,  531. 
secondary,  572. 
alopecia  in,  581. 
cutaneous  lesions  of,  573, 
papular  syphilides,  576. 
syphilitic  plaques,  576. 
with  large  plaques,  577. 
with  small  palques,  578. 
pigmentary  syphilide,  579. 
roseola,  573. 

Gibert.'s    pityriasis    rosea 
and,  575. 


Syphilis,     secondary,      cutaneous 
Resions   of,   roseola,    medica- 
mental  erythemas  and,  575. 
vesicular,  bulbous  and  pus- 
tular syphilides,  579. 
deafess  in,  586. 
general  phenomena  in,  572. 
icterus  in,  587. 
iritis  in,  586. 

lesions  of  mucous  membrane 
in,  582. 
of  cheeks,  583. 
of  mouth,  582. 
of  tongue,  583. 
lesions  of  nails  in,  582. 
lesions  of  pharynx  in,  584. 
in  soft  palate,  584. 
in  tonsils,  584. 
nephritis  in,  588. 
nervous  affections  in,  5S5. 
facial  paralysis,  586. 
headache,  585. 
hemiplegia,  585. 
lymphocytosis    of    cerebrd- 
spinal  fluid,  .586. 
meningo-myelitis, acute, 586. 
oculo-motor  paralysis,  586. 
optic  neuritis  in,  587. 
j)hlebitis  in,  588. 
retinitis  in,  587. 
sensory  organs  in,  587. 
visceral  affections  in,  585. 
social  consequences  of,  523. 
svniptoms  of,  536. 
tertiary,  588. 

diagnosis  of,  589. 
localization  of,  589. 
treatment  of,  591. 
of  active,  675. 
ambulatory,  690. 
attacking,  610. 
army.  649,  650. 
arsenical,  612. 
galyl  in,  636. 
he(!tine  in,  636. 
luargol  in,  637. 
neosalvarsan     (novarsonty- 
benzol)  in,  615. 

after-effects     of     concen- 
trated    injections     ol, 
628. 

dosage  for,  625. 
effect     of,     on     syphihtu; 
manifestations,  619. 
on    cutaneous    lesions, 
620. 

on     general     conditien, 
621. 


1098 


INDEX 


Syphilis,  treatment  of  Neosalvar- 
sam    in,    effect  of,   on 

headache,  620. 
on  hemiplegia,  620. 
on  iritis  and  irido-cho- 
roiditis,  621. 
on  mucous  plaques,  619 
on    syphilitic    chancre, 
619. 
periodicity    of   injections 
of,  62S. 

serious  accidents  in  treat- 
ment with,  631. 
acute  encephalitis,  632. 
albuminuria.  635. 
cardiac        disturbance, 

635. 
cutaneous       eruptions, 

635. 
gastro  -  intestinal    dis- 
orders, 635. 
icterus,  635. 
nervous  disorders,  633. 
neuro-rel apses,  633. 
vehicle  for  injections    of, 
616. 
salvarsan  in,  613. 
ulcerations  due  to,  557. 
clandestine    prostitution    and, 

694. 
energetic,  641. 
free  prostitution  and,  700. 
intravenous       injections      in, 
technique  of,  653.      (See  al- 
so Intravenous  injections), 
lonal,  644. 
mercurial,  593. 

by  endermic  administrating, 

600. 
by  ingestion,  594. 
cachets  in,  597. 
pills  in,  595. 
solutions   and   syrups   in, 

594. 
tabloids  in,  597. 
intra-muscular    administra- 
tion of,  600. 
bj'  injection  of   insoluble 
preparations,  601. 
advantage  of,  601. 
calomel  in,  603,  604. 
grey  oil  in,  603. 
inconvenience  of,  601. 
pain  of,  602. 
salicylate    of    mercury 

in,  603. 
yellow    oxide    of    mer- 
cury in,  603. 


Syphilis,  treatment  of,  morcurial, 
intra-muscular  admin- 
istration of,  by  injec- 
tions of  soluble  prepara- 
tions, 604,  605. 
benzoate  of  mercury  in, 

606. 
biniodide    of   mercury, 

in,  606. 
cyanide  of  mercury  in, 

607. 
neutral     salicylate     of 

mercury  in,  607. 
oxvcyanide  of  m3rcury 
in,  607. 
technique  of,  607. 
intravenous   administration 
of,  60S. 
advantages  of,  609. 
cyanide    of    mercury    in, 

608. 
objections  to,  609. 
technique  of,  609. 
value  of,  610. 
mercury  with  arsenic  in,63S. 
per  rectum.  599. 
of  munition  workers,  670. 
prostitutes  and,  694,  695,  69G. 
routine,  641. 

continued  treatment  in,  649. 
at  the  front,  649. 
in  depots  and  sedentary 

services,  650. 
Wassermann  reaction  in, 
651. 
pariod  of  chancre  in,  642. 

local  applications  in,  643. 
secondary  period  in,  644. 
local  applications  in,  644. 
for    papular    syphilides 
with    small    papules, 
645. 
for  ulcerations  of  skin, 
645. 
special  medication  in,  646. 
for  facial  paralysis,  646. 
for  headache,  646. 
for  hemiplegia,  647. 
for  iritis,  647. 
for   lesions   of   muscles 

and  bones,  648. 
for  nephritis,  648. 
Wassermann     Reaction     and, 
650. 
vaccination  in,  274. 
workmen's  accidents  and,  547. 
wounds  and,  524. 


INDEX 


1099 


Syphilitic  acne,  578. 
alopecia,  5<S1,  5S2. 
carriers,   isolation   of,   670,   073, 
r)75. 
Sypliilitic  chancre,  'yM\. 

coniniencenient  of,  538. 
diagnosis  of,  .545. 

coniplonient-fixation  test  in, 

554. 
evolution    of    chancre    and, 

547. 
objective  signs  in,  545. 
patient's      antecedents     in, 

547. 
secondary      svinptonis      in, 

547. 
laboratory  aid  in,  549. 
])arasite  in,  examination  for, 

549. 
Wasserniann  reaction  in, 
554. 
diagnostic  elements  of,  535. 
differential  diagnosis  of,  557. 
from  genital  heri)es,  557. 
from  simple  chancre,  558. 
from  ecthyma.  501. 
from  scabies,  501. 
from    common    excoriations 

of  genital  organs,  502. 
from    gangrene    of    genital 

organs,  502. 
from     ulcerations     induced 
with  object  of  simulation, 
503. 
from   erosive   and   ulcerous 

balanitis,  504. 
from  ei>ithelioma,  564. 
from  nuicous  plaques,  504. 
from  pseudo-chancre,  500. 
from     tertiary     ulceu'ations, 
505. 
cA'olution  of,  543. 
inoculation  of,  .542. 
localisation  of,  cau.ses,  537. 
multiple,  542. 
novarsenobenzol  and,  019. 
recurrent,  507. 
single,  542. 

stage  of  maturity  of,  ,538. 
treatment  of,  ()42,  043. 
unsuitable    remedies     applied 
to,  545,  540. 
Syphilitic  eruijtions,  520. 
lesions,  diagnosis  of,  530. 
mortahty,  525,  52(). 
and  female  labor,  519. 


Svphilitic   paiients    and    furlough, 
075,  070. 
roseola,  diagimsis  of,  575. 
typhosis,  104. 

T.  A.  H.  Vaccine,  2HS,  270  -78. 
Tabardillo,  487. 
Taruier  Clinic,  529,  530. 
Technique  of  antitoxin   iiiiuciion-i 
in  tetanus,  924. 
of  intramuscular  inject  iou>,  '107, 

008. 
of  intravenous  injections,  052. 
Temperature,      disortlers      of,      in 
cholera,  383. 
in  jjaratyphoid  fevers,  50,  82,  85. 
in     .second     phase     of     primary 
I>aludism  in  malaria.  902. 
a  pyrexia    l)etween   attacks   in, 

967,  968. 
irregular  fever  in,  907. 
isolated  attacks  in,  905. 
occiu'rence  of  attacks  in,  967. 
(juotidian    intermittent     fever 

in,  905. 
remittent   contimied   fever  in, 

902. 
tertian  attacks  in,  965. 
in    secondary    i)aludism    in    ma- 
laria, 1008. 
irregular  fever  in,  1011. 
isolated  fits  of  fever  in,  1010. 
quotidian    intermittent     fever 

in,  1010. 
septan  fever  in,  1010. 
tertian   intermittent    fever   in, 
1008. 
in  typhoid  fever,  5,  7,  52,  131 ,  149. 
amphibolic-  stage  of,  52,  55. 
antipyretic  measures  in,  133. 
chief  guide  to  treatment  of  ty- 

l)hoid  fever,  3. 
complications  affecting,  57. 
in  incubation  i)eriod,  53. 
in  height  of  disease,  54. 
in  onset,  53. 

in  period  of  defervescence,  bo. 
relations  of  pulse  to,  57. 
variations  in,  50. 
ordinary  course  of,  in  normal 

fever,  53. 
relation  of,  to  pulse,  57. 
Tenesmus  in  dysentery,  29G. 
Tertian  intermittent  fever  in  sec- 
ond    attacks     of     primary 
paludism,  865. 
in    secondary    jjaludisni   in   ma- 
laria, idos. 


1100 


INDEX 


Tertiary  lesions  in  syphilis,  diag- 
nosis of,  5S9,  590. 
syphilides,  557, 
syphilis,  58S. 

diagnosis  of,  589. 
localisation  of,  5S9. 
ulcerations  in  syphilis,  505. 
Testicle,  72. 

Testicular  atrophy,  5.31. 
Tetanic  bacillus.     (.See  Nicolaiir's 

bacillus. 
Tetanolysin,  824. 

Tetanus,  abnormal  forms  of,  sum- 
mary of,  915. 
attenuated,  developing  slowly 
with  prolonged  incubation, 
919. 
cephalic,  914. 

non-paralytic,  914. 
paralytic,  915. 
with  ophthalmoplegia,  910. 
with  paralysis  of  the  hypo- 
glossal, 910. 
localised    abdomino  -  thoracic 
type,  918. 
of  limbs,  917. 

monoplegic,  917. 
paraplegic,  918. 
splanchnic,  914. 
unilateral,  910. 
antitoxin,  920,  923. 
dosage  of,  923,  920. 
paths  of  injection  of,  923,  920. 
attenuated,  with  slow  develop- 
ment and  prolonged  incuba- 
tion, 919. 
atypical   forms   of,    707.         {See 

also  forms  by  name.) 
cephaUc,  707,  709. 
non-paralytic,  709. 
summary  of,  910. 
paralytic,  summary  of,  910. 
varieties  of,  707-708. 
with  facial  paralysis,  712. 
age   and  sex  in   occurrence 

of,  715. 
antitetanic       injection       of 

wound  in,  728. 
bacteriology  of,  720. 
characteristics  of,  712. 
clinical  picture  in,  715. 
diagnosis  of,  727. 

from  tic  douloureux,  727. 
from    traumatic    spasms, 

727-728. 
in   infectious  wounds   of 

face,  728. 
in    unilateral    symptoms, 
727. 


Tetanus,  cephalic,  with  facial  par- 
alysis, diagnosis  of,  dura- 
tion of,  720. 
etiology  and  frequency  of, 

714. 

facial  paralysis  in,  721. 

clinical  characters  of,  721. 

in  complete  peripheral 

facial  paralysis,  722. 

in    lower    facial    type, 

722. 
in  superior  facial  tvpe, 

723. 
in  total  facial  paralysis, 
723. 
commencement  of,  721. 
developinent  of,  724. 
diagnosis  of,  724. 
pathogenesis  of,  725. 
prognosis  in,  724. 
situation  of,  721. 
fever  in,  725. 
history  of,  713. 
incubation  in,  718. 
individual  signs  in,  717. 
muscular    contractions    in, 
719. 
degree  of,  719. 
extension  of,  720. 
in  paralysed  muscles,  719. 
in  side  not  paralysed,  720. 
prognosis  of,  720. 
situation  of  wound  in,  717. 
trismus  in,  718. 
Tetanus  cephalic,  with  ophtham Di- 
plegia, 729. 
clinical    manifestations    of, 
731. 
initial  symptoms  in,  731. 
pupillary     disorders     in, 

734. 
situation    of    ophthalmo- 
plegia in,  734. 
symptoms  of  ophthalmo- 
plegia in,  731. 
diagnosis  of,  737. 

false  ophthalmoplegia  in, 
737. 
con.stancy  of  spasms  in, 
738. 
hystero  -  traumatism     in, 

■  740. 
in    lesions    of    meningeal 
origin,  738. 
cerebro  -  spinal  menin- 
gitis in,  738. 
tubercular     meningitis 
in,  738. 
in  traumatic  lesions,  739. 


INDEX 


1101 


Tetanus,  cephalic,  with  ophthal- 
moplegia, diagnosis  of, 
in  traumatic  fracture  of 
orbit  and  base  of  skull 
in,  739. 
etiology  of,  730. 

occupation,  age  sex  in, 730. 
seat  of  infection  in,  730. 
history  of,  729. 
pathogenesis  of,  735. 
theories  of,  735-736. 
through  medium  of  moter 

nerves  of  the  face,  736. 
through  medium  of  trige- 
minal nerve,  736. 
prognosis  of,  741. 
summary  of,  916. 
Tetanus,  cephalic,  with  paralysis  of 
the  hypoglossal  nerve,  742. 
course  of,  742. 

signs  and  symptoms  of,  742. 
facial  paralysis  in,  743. 
ophthalmoplegia  in,   743. 
trismus  and  dysphagia  in, 
742. 
summary  of,  916. 
Tetanus,  cephalic,  without  paral- 
ysis, dysphagic,  710. 
hydrophobic,  711. 
pure,  710. 
simple,  710. 
varieties  of,  709. 
Tetanus,  cicatricial,  786. 
classical  form  of,  914. 
contamination    of    French    and 
Flemish  soil,  cause  of,  920. 
curative  treatment  of,  871. 
antitoxic  treatment  in,  880. 
alcohol  in,  883. 
ascitic  acid  in,  884. 
Bottu's  mixture  in,  886. 
carbolic  acid  in,  880. 
mode  of  action  of,  882. 
results  in,  881. 
cholesterin  in,  884. 
colloidal  metals  in,  883. 
hypochlorate  of  betain,  884. 
nervous  opotherapy  in^  884. 
salvarsan  in,  883. 
sodium  persulphate  in,  885, 
926. 
local  treatment  of  wound  in, 

871. 
procedure    recommended    in, 

907. 
serotherapy  in,  872. 

injections   in    contact   with 
wound  in,  880. 


Tetanus,    curative    treatment    of, 
serotherapy   in,    intra-ar- 
terial  injections  in,  877. 
intra-cerebral  injections  in, 

878. 
intramuscular  injections  in, 

875. 
intra- nervous  injections  in, 

879. 
intravenous    injections    in, 

875. 
para-nervous   injections    in, 

880. 
para-radicular  injections  in, 

880. 
sub-arachnoid  injections  in, 

878. 
subcutaneous  injections  in, 

874,  880. 
value  of,  872. 
sulphate  of  magnesium  in,  894, 
925. 
action    of,    on    circulation, 

897. 
experimental  action  of,  894. 
influence  of,  on  body  tem- 
perature, 896. 
mechanism  of  action  of,  and 
dosage,  897. 
clinical  results  in,  900. 
experimental    results    in , 

900. 
intrarachidian    injections 

in,  899. 
intravenous  injections  in, 

897. 
subcutaneous      injections 
in,  897. 
mode  of  administration  of, 
and  dosage,  902. 
intrarachidian    injections 

in,  903. 
intravenous  injections  in, 

904. 
subcutaneous     injections 
in,  902. 
surgical  measures  in,  905. 
bilateral    phrenicotomy    in, 

905. 
tracheotomy  in,  905. 
symptomatic,  887. 
hygiene  in,  887. 
sedatives  in,  889. 
belladonna,  889. 
chloral,  889. 
curare,  889,  925. 
ether,  889. 
hyoscamus,  889. 


1102 


INDEX 


Totainis,    furative    ti'oatnioiit    of. 
symptom  a  tic,      .so(iativo.s 
in,  morphia,  889. 
potassium  bromide,  889. 
warm  baths  in,  888. 
ultra  violet  light  in,  925. 
Tetanus,     following     exposure     to 
cold   and  wet,   921. 
gas  gangrene  coincident  with,92j0. 
general    treatment    of    patients 

in,  925,  920. 
importance  of  foot-wear  in,  921. 
in  typhoid  fever,  18. 
incubation  period  in,  922. 
insidious  onset  of,  922. 
late  api)earance  of,  922. 
Tetanus,  local,   abdomino-thoracic 
form  of,  811. 
ca.se,  P.  L.  Marie,  811. 
development  of,  815. 
mode  of  entrance  in,  814. 
pathogenesis  of,  815. 
attenuated  forms  of,  with  slow 
development     and      pro- 
longed incubation,  817. 
pathogenesis  of,  817. 
symptoms  of,  817. 

facial  expression  in,  818. 
hyper   -    excitability      of 
muscles  and  nerves  in, 
819. 
muscular    hypertonia    in, 
818. 
definition  of,  781. 
development  of,  837. 

nature     of,     sub-acute     or 

chronic,  837. 
period  of  onset  of,  838. 
.second  period  f)f,  or  period 
of   permanent,    non-i>ain- 
ful  contractm-es,  838. 
third  period  of,  839. 
etiology  of,  821. 

adjuvant  factors  in,  832. 
atmospheric      conditions, 
832. 
cold,  832. 
hunndity,  832. 
chemical  substances,  833. 
secondary  infection,  832. 
causal  agent  in  (Nicolaier's 
bacillus),  821. 
biological  propertiesof, 823. 
agglutinabilit.v  in,  824. 
gas  formation  in,  824. 
luemol.ysia  in, 824. 
indol  formation  in,  824. 
vitality  in,  823. 


Tetanus,  local,  etiology  of,   causal 
agent  in,  cultures  of,  822. 
experimental    pathogenic 
action  of,  824. 
inoculation    with    pure 

cultures  in,  825. 
inoculation  with  tetan- 
iferous  pus  or  soil  in, 
825. 
isolation   and   cultivation 

of,  821. 
n;obility  of,  822. 
morpholog.v  of,  822. 
staining  of,  822. 
direct  contact  in,  834. 
habitat  of  bacillus  in,  828. 
soil  as,  828. 

in    European   war   reg- 
ions, 829. 
straw  as,  830. 
infection   of  wound  in,   ac- 
tion of,  830. 
nature  of  woinid  in,  831. 
situation  of  wound  in,  831. 
toxin  in,  82(5. 

method  of  preparation  of, 

826. 
mode  of  action  of,  827. 
nature  and  proi)erties  of, 
826. 
forms  of,  780. 
frequency  of,  820. 
history  of,  780. 
monoplegic  form  of,  783. 
diagnosis  of,  796. 

bacteriological     examina- 
tion for  ba(!illus  in,   796. 
differential  diagnosis  of,  797. 
from     acute     strychnine, 

poisoning,  802. 
from     contractures    or 
pseudo    -    contractures 
following  lesions,  799. 
from    contractures   of   te- 
tany, 800. 
forcible    extension    and 
flexion  of  lower  limbs 
in,  802. 
Chvostek's  sign  in,  801. 
h  .V  ijcrexcit ability 
of  nuiscles  and  nerves 
to  galvanism  in,  802. 
Trousseau's  sign  in,  801. 
Weiss's  sign  in,  801. 
from    excitation    or    irri- 
tation   of    motor    and 
mixed     nerves    due    to 
lesions,  798. 


INDEX 


1103 


Totaiuis,    looal,    monoplegio  form 
of,,  differential   diagnosis 
of,  from  hvsterial  contrac- 
tures, 803. 
from     incomplete     hemi- 
plegia, 798. 
from     spasmodic     mono- 
plegia   of    cerebral    or 
medullary  origin,  798. 
period  of  acme  in,  790. 
blood  in,  795. 
cerebro-spinal     fluid     in, 

795. 
contractures  in,  790,  791. 
clonic    movements    in, 

791. 

generalized  tonic  form 

(rigidity)     of,      791. 

general  indications  in,' 793. 

facial  aspect  in,  794. 

hypersensitiveness     in, 

794. 
pulse  in,  794. 
respiration  in,  794. 
urine  in,  794. 
pain  in,  790. 
reflexes  in,  795. 
summary  of,  795. 
period  of  incubation  in,  793. 
in     early     or     precocious 

tetanus,  783. 
in  late-appearing  tetanus, 
784. 
due  to  surgical  trauma- 
tism, 784,  785. 
explanation      of,     784. 
period  of  onset  in,  785. 

general  symptoms  in,  788. 
exaggeration  of  reflexes 

in,  789. 
facial     expression     in, 

789. 
temperature  in,  789. 
local  signs  in,  786. 
cramps  in,  787. 
pain  in,  786. 
skin  in,  786. 
spasms  in,  786-787. 
stiffness  in,  788. 
summary  of  symptoms  in, 
r  '  "  790. 
Tetanus,  local,  paraplegic  form  of, 
805. 
diagnosis  of,  809. 
differential      diagnosis      of, 
from    cerebro-spinal    me- 
ningitis, 809. 


Tetanus,  local,  paraplegic  form  of, 
symptomatology  of,  805. 
in  inferior  type,  806. 

contractures    of    limbs 

in,  806. 
muscular  rigidity  of  ab- 
dominal wall  in,  806. 
in  superior  type.  807. 
pain  in,  807. 
reflexes  in,  808. 
summary  of,  808. 
temperature  in,  808. 
types  of,  805. 
paraplegic  onset  of,  781. 
pathogenesis  of,  834. 
factors  in,  835. 
mode  of  arrest  in,  835. 
process  of,  834. 
prognosis  of,  840. 

abdominal     muscular     con* 

tracture  in,  842. 
deglutination  in,  843. 
in  atypical  form,  840. 
localization  in,  840. 
period   of  incubation   in, 

841. 
temperature  in,  840. 
in  classical  form  841. 
pulse  in,  842. 
temperature  in,  842. 
other  bacteria  in,  843. 
summary  of,  843. 
Tetanus,  localised  abdomino-thor- 
acic    type  of,  summary    of, 
918. 
mortality  in,  920. 
of  limbs,  745. 

atypical  forms  of,  745. 
cases  of,  746. 
summary  of,  917. 

monoplegic  type,  917. 
paraplegic  type,  918. 
pathway  of  infection  in,  922. 
predisposing  conditions  in,  921. 
pre-existing  oedema  in,  921. 
present  status  of  knowledge  on, 

922. 
prognosis  of,  922-926. 
prophylactic  treatment  of,  845. 
cold    in,    prevention-   against, 

852. 
contagion  in,  851. 
local  treatment  in,  846. 
amputations  in,  846. 
antisepsis  in,  847. 

antitetanic  serum  in.  des- 
sicated  and  powdered^ 
849. 


1104 


INDEX 


Tetanus,  local,  prophylactic  treat- 
ment   of,    antisepsis     in, 
chemical  agents  for,  847. 
calcium      hvpochloride 

in,  849. 
oxygen,  847. 
tincture  of  iodine,  847. 
phj^sical  agents  in,  849. 
hot  or  cold  air,  849. 
light,  850. 
search  for  projectiles  in.  840. 
serotherapy  in,  852,  920,  9212. 
abuse  of  heterogeneous  ser- 
ums in,  804. 
antitetanic  serum  in,  852. 
anaphylaxis  from,  809. 
a  n  t  i  -  anaphyhicf ic 
measures  in,  804,  S()5. 
dosage  in,  870. 
efficacy  of,  805. 
liistory  of,  852. 
innocuousness  of,  8.58. 
])rep;u'ation  of,  85;i. 
j)roperties  of,  854. 
antitoxic,  854. 
propliylactic,  855. 
rules  of  injection  of,  807. 
salol  as  adjuvant  in,  871. 
symptoms    due    to     first 
injection  of,  858. 
eruptions,  858. 
fatal,  800. 

serum  sickness.  809. 
symptoms  due  to  re-injec- 
tion of,  801,  809. 
inunediate,  801,  809. 
late-  ai)pcaring,  801, 
870. 
splauchmV,  707,  70S    921. 

clinical  manifestations  of,  708. 
course  and  piognosis  of,  709. 
suinmarv  of,  914. 
treatment  of,  845,  922-936. 

war  cases  in,  740  <•/  scq. 
.unilateral,  743,910. 
Tetany,  coinj)licating  paiatyphoid 
fever.s,  90. 
differentiation    of,    from    mono- 
l)legic  form  of  local  tetanus, 
800. 
Chvostek's  sign  in,  801. 
forcible  extension  and  flexion 

of  lower  limbs  in,  802. 
hyjjerexcitability    of    muscles 
and  nerves  to  galvanism  in, 
802. 
Trou.sseau's  sign  in,  801. 
Weiss'd  sign  in,  801. 


Tetraoxydiphosphaminodiarsen- 
benzene,  030. 

Thick  drop  method  in  blood  exam- 
ination, 1033. 

Thomson,  vaccination  against 
bacillary  dysentery,  370. 

Three-day  fever  in  typhoid,  232. 

Throat,  sore,  in  syphilis,  521. 

Thrombo-phlebitis,  43. 

Thrombosis,  venous  in  typhoid,  22. 

Thrush  in  typhoid,  27. 
in  syphilis,  583. 

Thyroid  gland,  in  tyiihoid,  72. 

Tic  douloureux  differentiated  from 
cephalic  tetanus  with  facial 
l)aralysis,  727. 

Tincture  of  iodine,  .593. 

Tinnitus  in  syphilis,  .580,  033. 

Tobacco,  sui)pression  of,  in  sy- 
philis, GOO, 

Tongue,  lesions  of,  in  syphilis,  .583. 
in  typhus  exanthematicus,  402. 

Tonics  in  tvphoid,  143. 

Tonsil,  chancre  of,  570,  571,  044. 
and  the  typhoid  bacillus,  175. 

Tourniquet,  054,  05.5. 

Tours,  epidemics  of  typhoid  fever 
at,  -242,  254,  272,  288. 

Toxin  of  tetanus,  820. 

destruction  of,  by  light  rays,  850. 
method  of  preparation  of,  820. 
mode  of  action  of,  827. 
nature  and  properties  of,  820. 

Tiacheotomy  in  treatment  of  te- 
taims.  905. 

Transfusion  in  cholera,  407,  408. 

Transvaal  War,  enteric  (typhoid 
fever)  (uxses  in,  102. 

Traumatica  lesions, cephalic  tetanus- 
with  ophthalmoplegia  dif- 
ferentiated from,  739. 
spasms  of  face,  differentiation  of, 
from  cephalic  tetanus  with 
facial  paral.ysis,  727. 

Traumatic  ulcerations  in  s.vphilis, 
557.  _     \ 

Tremors  in  typhoid,  ftO. 

Trench  diarrlura,  308,  311,  309. 

Trenches,  tvphoid  contagion  in, 
2.50. 

Trcponcnin     pallidum,     549,     551, 
552. 
microscopical     examination     of, 
550. 
by  Giem.sa's  method,  550. 
ultra-microscope  method,  49. 

Trichomonas  intestinalis,  308. 


INDEX 


1105 


'l'iit?oinii;il  tioive,  r)iii;iM  of  infoc- 
t  ion  ill  cephalic  (t»(  aiiii?  wit  h 
o|)lithalino[)legia      throuf^h, 

7:u\. 

'rri.siims   in    ceplialic   lehinus    with 

facial  |)ar;il.\'sis,  7 IS. 
Troops,  pamphk'ls  on  svphili.s  for, 

'!\i!)orcular  nienin<;itis,  manifesta- 
tions of,  (Hlforentiated  from 
cephalic      t  e  t  a  n  u  s      wit,h 
oplithalmoplonia,  7)58. 
Tnl)orculosis  anO  syphilis,  olS. 
foUicMilar,  570. 
in  tvi)hoi(l  fever,  17. 
military,  100. 

(piestioii     of    A'accination     in, 
274. 
Tuberculous  meninf?itis,   difficulty 

of  diagnosis,  104. 
Tumefaction  of  cliancre,  542. 
Tunis    expedition,     dysentery    in, 
340. 
mortalitv      from      typhoid      in, 

2L  101. 
recrudescence   of   typhoid    fever 
in  the,  174. 
Turco-Ru.ssian  War,  tvphoid  infec- 
tion in,  Kjl,  207. 
Turkey,  cholera  in,  412. 

Typhisation  in  small  doses",  400. 
Typhoid  bacillus,  104,  175  ct  sc(j. 
cultural  reactions  of,  113. 
differentiated     from     paraty- 
phoid bacilli  A  and  B,  and 
bacillus  coH,  113,  114-115. 
aK^liitinabilitv  in,  1 10. 
intermediate  bacilli  in,  117. 
bacillus  faicales   alkaliKcnes 
and, 117. 
dii-ect  transmission  of,  lOS  ct 

•se.q. 
epide  nics  due  to,  254 
inert    factors   in    transm'ssipn 
of,    204    cl    seq.       {xice    altio 
Carriers.) 
influence  of  heat  on.  205. 
intermediate  bacilli  and,  1 17. 
investigation  of  the,  107  el  .ser/. 
life  of,  205. 
inicroscoi)ical,  examination  of, 

113. 
milk  as  conveyor  of,  238.   (See 

also  Milk.) 
occurrence  of,  in  body,  108. 
op.sonic  index  for,  121. 
reaction    of    fixation   of    com- 
plement in  test  for,  121. 


Tyi)hoid     bacilbn,     techni(4ue     of 
blood  culture  of,  111. 
te(!hni(iue  of  isolation  of,  from 
bile,  110. 
from  fiecos,  108. 
from  lenticular  rose  spots,  109. 
\N'idars    serum    test    in    diajt- 
nosis  of,  118. 
in  non-vaccinated,  118. 
in  vaccinated,  11 'J. 
bacteriuria,  1 10. 
Typho'd  fever,  abdominal  pain  and 
tenderness  in, 30. 
abortive,  10 
abscesses    and    i)hle!Jcmons    in, 

treatment  of,  147. 
aiie  and  sex  affected,  12  cl  seq., 
170,  171.225. 
alcohol  in,  143. 
amphibolic  staf?e  in  temperature 

in,  55. 
analysis  of  sy!ni)toms  and  com- 
plications, 2(). 
and  the  nervous  system,  58. 
antipyretic  measures  in,  133. 
by  external  api)lications,  133. 
affusions  in,  133. 
baths  in,  134. 

Brand's    method    of    k'v- 

injj;,  134. 
hot,  137. 
warm,   gradually   cliilled, 

130. 
warm  or  tepid,  130. 
compresses  in,  138. 
rectal  enemata  in,  138. 
rectal  instillations  in,  138. 
refriKoration  by  cold  air  in, 

138. 
spouf^ins  in,  133. 
wet  packs  in,  134. 
by  internal  medication,  140. 
antipyrine  in,  140. 
cryoKcniue  in,  140. 
pyramidon  in,  140. 
quinine  in,  140. 
antiseptic  medication  in,  142. 
appearance  of  tonj^ue  in,  2(». 
appetite  in,  20. 
apyretic  form  of,  12. 
arteries  in,  44. 
arteritis,  44. 
firthritic  form  of,  9. 
arthritis  in,  monarticular,  75. 
ataxo-dynamic,  12. 
associated  with  malaria,  1010. 
bedsores  in,  treatment  of,  147. 
bilious,  9. 


1106 


INDEX 


Typhoid  fever,  bladder  in,  70. 
bleeding  in  treatment  of,  141. 
blood  in,  45  et  seq. 
bronchial  form  of,  9. 
bronchitis  in,  39. 
bucco-pharyngeal  ulcerations  in, 

27-29. 
cardiac  complications,  146. 

treatment  of,  146. 
carphology  in,  60. 
Chantemesse's    ophthalmo-reac- 

tion  in,  105. 
children  as  carriers  of,  and  sus- 
ceptibility to,  ISO. 
cholera  in,  18: 
cholecystitis  in,  67. 
circulatory  system  in,  41. 
clinical  characters  of,  3  et  seq. 
clinical  diagaosis  of,  96  et  seq. 
clinical  study  of,  1. 
complications  in,  17,  22. 

treatment  of,  143. 
compulsory  notification  in,  233. 
constipation  in,  144. 

treatment  of,  144. 
contagion  in,  179  et  seq. 
convalescence  in,  21. 

complications  in,  22. 
cutaneous  complications  of,  147. 

treatment  of,  147. 
death  of  patients  in,  20. 
delirium  in,  60. 
diagnosis  of,  98. 

by   laboratory    methods,    107 
et  seq. 
diarrhoea  in,  26,  31,  144. 

treatment  of,  144. 
diet  of  patients,  128  et  seq. 
different  forms  of,  8  et  seq. 
differentiated  from  paratyphoid 

from  typhus,  100,  468. 
digestive  symptoms  in,  26. 
diphtheria  in,  17. 
direct  contagion  of,  198  et  seq. 
diseases  with  which  it  maj^   be 

confounded,  98  et  seq. 
disinfection  in,  233. 
diuretics  in,  143. 
drugs    for    combating    infection 

in.  143. 
Duguet's  ulcerations  in,  28. 
enteric,  162. 

enterococcus  infections  and,  101 
epidemiology  of,  156  et  seq. 
epidemics  of,  209,  211,  215.  216, 

223,  239,  242,  254,  272,  287, 

288. 


Typhoid  fever,  eruptions  in,  76. 
erysipelas  in,  18. 
etiology.  164  et  seq. 

favoring  causes  in,  164  et  seq. 
age  and  sex  factors  in,  170. 
familial    predisposition    in, 

168. 
racial  susceptibility  in,  168. 
repeated  attacks  in,  168. 
role  of  climate  in,  166. 
role  of  fatigue  in,  173. 
role  of  seasons  in,  165. 
rural     vs.     urban     suscepti- 
bility in,  170. 
susceptibility    of    army    in, 
172. 
foci  of  contagion  in  body,  175. 
importance  of,  182. 
in  blood,  176. 
in  faeces,  179. 
in  gall-bladder,  178. 
in  intestine,  176. 
in  tonsils,  175. 
in  urine,  181. 
in  viscera,  177. 
role  of  bacillus  carriers  in,  186. 
classification  of,  189. 

biliary  or  faecal  carriers, 

189. 
chronic,  189. 
urinary  carriers,  192. 
exposure    to    contagion    by, 

196. 
history  of  epidemics  caused 

by,  193. 
precautions  against,  195. 
transmission    of   infection    in, 
182. 

by  direct  agents: 
by  corpses,  184. 
by     pharyngeal     lesions, 

183. 
by    vomit    and    excreta, 
183-184. 
bv  indirect  means: 
■  by  clothing,  205. 
by     country     contamina- 
tion, 206. 
bv  flies.  217. 
by  street  dirt,  206. 
by  vegetables,  208. 
from    beverages    contain- 
ing water,  216. 
from  drinking  water,  210. 
from  milk,  217. 
from  oysters,  209. 
in  camps,  207. 


INDEX 


1107 


Typhoid    fever,    exanthemata    in, 
acute,  17. 
febricula  in,  11. 
febrile  foi:m  of.  in  infants,  14. 
infections  simulating,  100. 
reactions  in,  271,  277  inute). 
female  genital  organs  in,  73. 
fixation  abscess  in,  141. 
fbod  and,  238. 

form  of,  in  first  phase  of  primary 
paludism  in  malaria,  954. 
differentiated     from     typhoid 

fever,  957. 
general  symptoms  of,  954. 
pulse  in,  955. 
temperature  in,  955. 
forms  of,  symptomatic,  9.. 
with  special  onset,  8. 
with  variations  in  course,  11 . 
with  variations  in  seventy,  11. 
frequency  of,  156. 
gangrene  of  skin  in,  78. 
gastric,  9. 

symptoms  in,  29. 
gastro-intestinal  form  of,  in  in- 
fancy, 13. 
gurgling  in,  intestinal,  30. 
haemorrhagic  form  of,  9. 
headache  in,  62. 

treatment  of,  147. 
hearing  in,  66. 
height  of  disease  in,  5,  8. 
hepatic  abscesses  in,  68. 
human  factor  in,  175  et  seq. 
hygiene  of  genito-urinary  organs, 
in,  127. 
of  patients,  123  ei  seq. 
of  skin  in,  125. 
hygiene  of  skin  in,  125, 
hyperpyretic,  12. 
icterus  gravis  and,  103. 
importance     of    laboratory     re- 
search in,  1. 
in  alcoholic  patients,  18. 
in  aged,  16. 

in  armies,  during  peace,  158. 
during  war,  159,  248. 
in  Boer  War,  162. 
in  Civil  War,  160. 
in  European  War,  163. 
in    Franco  -  German    War, 

161. 
in       German       Expedition 
against  Herreros,  162. 
in    Russo  -  Japanese    War, 

162. 
in  South  Orau  Expedition, 
161. 


Typhoid  fever  in  Spanish-.\nieri('an 
War,  161. 
in  Tunis  Expedition,  161. 
in  Turko-Russian  War,  101. 
in  cardiac  diseases,  19. 
in  children,  12,  14. 
in  diabetics,  18. 
in  infancy,  12. 
in  influenza,  17. 
in  malaria,  18. 

in  pathological  conditions,  17. 
in  pregnancy,  16. 
in  pulmonary  diseases,  19. 
in  tuberculosis,  17. 
incubation  periods  of,  3,  7,  179. 
indirect  contagion  by  patients  or ' 

carriers  in,  204  et  seq. 
infective  endocarditis  and,  103. 
influenza  and,  98. 
injections  in,  143. 
insidious  form  of,  11. 
insomnia  in,  59. 

intestinal    haemorrhage    in,     32, 
145. 

treatment  of,  145. 
intestinal  perforation  in,  33,  145. 

treatment  of,  145. 
intestinal  symptoms  in,  .30. 
isolation  in,  232. 
jaundice  in,  66. 
kidney  in,  69. 
laryngeal  symptoms  in,  38. 
latent  form  of ,  1 1 . 
liver  and  gall  bladder  in,  66  et 

seq. 
lymphatic  glands  in,  73. 
malaria  and,  102,  954. 

differentiation    of,     from     ty- 
phoid fever,  957. 
Mediterranean  fever  and,  101. 
meningeal  form  of,  9. 

in  infants,  13. 
meningeal  syndromes  in,  64. 

mental  disturbances  following, 
24.  25. 
meteorism  in,  30. 
military  tuberculosis  and  acute, 

100. 
mortality  in,  21,  156-159. 
motor  troubles  in,  63. 
mouth  in,  26,  28. 
muscular  rupture  in,  74. 

system  in,  74. 
myocarditis  in,  41. 
nasal  symptoms  in,  38. 
nephritis,  acute,  and,  104. 
nervous  complications  of,  treat- 
ment of,  147. 


1108 


INDEX 


Typhoid  fever,  nervous  symptoms 
in,  58. 
meningeal  syndromes,  64. 
motor  disturbances,  63. 
psychical  disturbances,  60. 
sensory  disturbances,  62. 
typhoid  state  in,  59. 
not  a  purely  intestinal  affection, 

1. 
nourishment    in,     necessity    of, 

130. 
opsonic  index  in,  121. 
ordinary  course  of  temperature 
in,  53. 
form  of,  special  features  of,  7. 
osseous  system  in,  75. 
otitis  media  in,  suppurative,  66. 
pancreas  in,  72. 
paralysis  in,  64. 
periostitis  in,  75. 
period  of  defervescence,  6,  8. 
period  of  invasion  or  onset,  4,  7. 

sudden  beginning  of,  8. 
peritonitis  in,  treatment  of,  145. 
peritoneum  in,  68. 
pharyngeal  ulcerations  in,  29. 
phlebitis  in,  43. 

pleural  complications  in,  40,  147. 
pleurisy   in,    serous    or   hgemor- 

rhagic,  treatment  of,  147. 
pleuritic  form  of,  9. 
pneumonia  in,  18,  39. 

lobar,  103. 
pneumonic  form  of,  8. 
polioencephalitis  in,  acute,  63. 
prolonged,  10. 

prophylaxis  of,  225  et  seg'.,231  et 
seq.,  242  et  seq. 
age  in,  225. 

bacteriological  study  in,  229. 
fatigue  in,  226. 
heat  in,  226. 
hygiene  in,  227. 
in  camps,  227. 
popular  education  regarding, 

229. 
specific  measures  in,  231. 
regarding  carriers,  234. 
regarding    drinking    water, 

236. 
regarding  flies,  240. 
regarding    milk,    cider    and 

other  beverages,  238. 
regarding  oysters,  239. 
regarding  patient,  232. 
disinfection  in,  233. 
notification  in,  233. 
regarding  vegetables,  238. 


Typhoid  fever,  prostration  in,  5d. 
psychical  disturbances  in,  60. 
puerperal  fever  and,  104. 
pulmonary  complications  in,  39^, 
146,  183. 
treatment  of,  146. 
pulsa  in,  49. 
dicrotic,  51. 

relation  of  temperance  to,  57. 
purgatives  and  laxatives  in,  142. 
pyaemia  and,  104. 
recovery  in,  21. 
recrudescences  in,  10,  23. 
recurrence  of  epidemics  or  eh- 

demics  in,  193. 
reflexes  in,  63. 
relapses  in,  23. 

cause  of,  24. 
renal  form  of,  69. 
resemblance  of  other  forms  to, 

96  et  seq. 
respiration  in,  38. 
respiratory  system  in,  38  et  seq. 
rheumatism  and,  102. 
role  of  drinking  water  in,  210. 
scarlatina  in,  17. 
salivary  glands  in,  72. 
second  attacks  in,  23. 

course  of,  24. 
sensory  troubles  in,  62. 
septicaemia  and,  104. 
sequelae  of,  24. 
serum  diagno^s  of,  47. 
serum  therapy  of,  149. 
skin  in,  76  et  seq. 
somnolence  in,  59. 
special  senses  affected  by,  65. 
specific  prophylaxis  of,  231  et  seq. 
specific  treatment  of,  148. 
spleen,  in  enlargement  of,  37,  83, 

106. 
streptococcal  infection  in,  18. 
stupor  in,  59. 
suitable  drinks  for,  129. 
suprarenal  capsules  in,  73. 
susceptibility  of  soldiers  to,  158 
syphilis   and,  malignant  hyper- 
toxic,  104. 
symptoms  of,  26. 
temperature  in,  3,  5,  7,  52,  131, 
149  et  seq. 

amphibolic  stage  of,  55. 

complications  affecting,  57. 

in  incubation  period,  53. 

in  height  of  disease,  54, 

in  onset,  53. 

in  period  of  deferescence,  55, 


INDEX 


1109 


Typhoid  fever,  temperature  of,  re- 
lation of  iiulse  to,  57. 
variation  in,  56. 
termination  of,  20. 
tetanus  in,  18. 
testicle  in,  72. 
thrush  in,  27. 
thyroid  gland  in,  72. 
toilet  of  mouth  and  nasal  fossie 

in,  124. 
tongue  in,  27,  28. 
tonics  in,  14.3. 
tonsils  in,  175. 

transmission  of,  by  direct  con- 
tagion, 198. 
role  of  carriers  in,  199-200. 
role  of  hands  in,  199. 
by  indirect  contagion,  201. 
role  of  carriers  in,  201. 
treatment  of,  123  et  seq. 
of  complications,  143. 
tremors  and  muscular  twitchings 

in,  60. 
tuberculosis  and,  17. 
tuberculous  meningitis  and,  104, 
tj'phoid  bacillus  in,   164,   175  et 

seq: 
typho-tuberculosis  and,  101. 
typhus  and,  99. 
ulcerations  in,  bucco-pharyngeal , 

27,  28.' 
urinary  disorders  in,  69,  70,  147. 

treatment  of,  147. 
urine  in,  70. 

diazo-reaction  in,  71. 
vaccination    in,    234,    236.    273. 
See    also  Vaccination,  and  Vac- 
cines, 
vaccinia  in,  17. 
vaccine  therapy  of,  149. 

indications    and    contra-indi- 

cations  for,  152. 
results  of,  153. 
technique  of,  152,  153. 
vaccines  used  for: 

bacilli  killed  by  heat,  150. 
polyvalent     bafiillary     vac- 
cine sterilized  with  ether, 
151. 
vaccines    of    living    bacilli, 
150. 
various  glands  and  systems  in, 

72  et  seq. 
variola  in,  17. 
various  modes  of  treatmeTit  of 

141. 
veins  in,  43. 
vision  in,  65. 


Typhoid  fever,  vomiting  in,  29, 144. 
treatment  of,  144. 
Vincent's     spleno-diagnosia     in, 

106. 
with    secondary    complication3, 
243. 
Typhoid  myelitis,  64. 
myositis,  74. 
phlebitis,  43. 
pleuro-,  9. 
pyaemia,  79. 
septiieaemia,  1. 
state  in  cholera,  391. 

nervous  symptoms  of,  59. 
Typhoidal  dysentery,  302. 
Typho-malaria,  20. 
Typho-malarial  fever,  19,  20. 
Tj'pho-tuberculosis   of   Landouzy, 

101. 
Typhus  exanthematicuS,  99,  457. 
clinical  forms  of,  465. 
complications  of,  464. 
diagnosis  of,  467. 
differential  diagnosis  of,  468. 
from   cerebro-spinal    meningi- 
tis, 469. 
from  influenza,  470. 
from  malarial  fever,  469. 
from  measles,  469. 
from  pneumonia  of  apex,  470. 
from  relapsing  fever,  469. 
from  Rocky  Mountain  spotted 

fever,  470. 
from  typhoid  fever,  468. 
"mixed  malady"  in,  471. 
epidemiology  of,  475-481. 
epidemics  of,  in  times  of  peace, 
479. 
in  war-times,  475. 
eruption  of,  458-463. 
etiology  of,  482-496. 

determining  causes  of,  virus  of 
typhus,  486. 
effect  of  heat  on,  493.     ^ 
inoculation  of,   by  infected 
blood.  487. 

immunity  of  serum  after 
recovery,  488. 
localisation     of,     in     leuco- 
cytes, 489. 
propagation  of,  493-494. 

by  famine-stricken.  495. 
transmission    of,    by    body 
hce,  490. 

method  of  inoculation, 
492. 
by  polluted  instruments, 
-492. 


1110 


INDEX 


Typhus  exantliomiiticus,  etiology 
of,  predisposinaj  causes  in,  4S2. 
history  of,  475-481. 
mortahty  in,  463. 
pathogenic  agent  of,  experimen- 
tal, by  inoculation,  486-487. 
prophylaxi.s  of,  497-503. 

campaign  against  lice  in,  499. 
care  of  patient  in,  497. 
education  in,  499. 
i.solation   and   disinfection    in, 

497-498. 
nurses  and  clothing  in,  498. 
.serum  immunization  in,  499. 
symptomatology  of,  457. 
period  of  eruption  in,  458. 
erythema  in,  460. 
exanthemata  in,  459. 

early  appearance  of,  460. 
fugitive  nature  of,  460. 
morbid  symptoms  in,  460. 
deceptive    remission     of. 

461. 
second  critical  jwriod  of, 
461. 
delirium  in,  461. 
prostration  in,  461. 
reflexes  in,  463. 
sign  of  the  tongue  in,  462. 
l)eriod  of  incubation  in,  457. 
period  of  invasion  in,  458. 
period  of  termination  in,  463. 
treatment  of,  472-474. 

intravenous  infection  of  blood 

in,  473. 
serotherapeutic,  of  Nicolle  and 

lilaizot,  473-474. 
.serum  injections  in,  473. 
symptomatic,  472. 
Typhus  levissinuis,  10,  180,  466. 
'siderans,  466. 

Ulceration  in  dysentery,  301. 

dressing  of,  330. 
in  .syphilis,  562. 

cigarette  burns  and,  563. 

due    to    arsenical    treatment, 
555. 

induced  for  sinmlatioii,  557. 

of  skin,  645: 

tertiary,  565. 

traumatic,  557. 
in  typhoid,  bucco-pharyngeul.27. 

pharyngeal,  29. 

treatment  of,  126. 
Ulcerative  .syphilides,  .579. 
Ulcerous  balanitis,  564. 
Ulcers,  Duguct's,  6,  28,  82,  183. 


Ultra-microscopic  method  in  diag- 
nosis, 551,  552. 
Ultra-violet    light    in     preventive 
treatment  of  wounds  against 
tetanus,  850,  925. 
Undulant  fever,  102. 
Unioity  of  chancre,  542. 
Urismia  in  syphilis,  588. 
Urethra,  chancres  of,  643. 
Urinary  complications  in  tyhpoid, 

treatment  of,  147. 
Urinary     syndryomes     in     second 
phase  of  primary  paludism 
in  malaria,  988. 
albuminuria,  988. 
haimoglobimu'ic    fever    in    early 
bilious,  989. 
Urme  in  typhoid  fever,  70. 
diazo-reaction  in.  71. 
colour  test  for,  71. 
typhoid  bacilli  in,  181. 

Vaccination   against   cholera,   448. 

Vaccination  against  dysentery,  375. 

Vaccination  against  typhoid,  234, 

236,  248,  252,  255,  262,  263 

et  seq. 

compulsory,  242. 

contra-indications    to   use   of, 

273. 
employment  of,  280. 
febrile     reactions,     271,     277 

{note). 
human,  institution  of,  263. 
in  tuberculous  cases,  274. 
malaria  and,  273. 
mixed,  268. 
results  of,  280  et  seq. 
svphilitic  cases  in,  274. 
the  most  powerful  prophylac- 
tic measure  against  typhoid 
fever,  290. 
typhoid  and  antityphoid,  120. 
value  of,  163,  280.  . 

Vaccine,  antidysenteri(5,  375-376. 
therapy  of  typhoid,  149  el  seq. 
doses  in,  277,  278. 
indications     and     contra-indica- 
tions for,  152. 
results  of,  153. 
technique  of,  152-153.  270. 
vaccines  used  for,  264. 

bacilli  killed  by  heat,  150. 
polyvalent    bacillary    vaccine 

sterilized  with  ether,  151. 
opacity-meter  for,  269. 
vaccines  of  living  bacilli,  13U. 


INDEX 


1111 


Vaccinia  in  typhoid  fever,  17. 
Vagrants,  inspection  of,  with  dys- 
entery, 445. 
Vaillard,  535,  692. 

investigations  on  serum  therapy 

of  tetanvis,  852. 
and  Vincent,  experiment  on  sec- 
ondary infection   as  an   aid 
to  development  of  tetanus, 
S33. 
Val-de-Grace  laboratory  anti-chol- 
era vaccine,  452. 
Vallette     and     Leriche,     cases     of 
monoplegic  tetanus  with  ac- 
celeration   of    development 
of  process  by  surgical  trau- 
matism, 785. 
Van  Swieten's  Liquor,  594. 
Variola  in  typhoid  fever,  17. 
Vegetables,  contagion  by,  208. 
prophylaxis  against,  238. 
Veins,  in  typhoid,  43. 
Venereal  danger,  instructions  as  to, 
682. 
disease,  discussion  on,  678. 
diseases    in    army    statistics    of, 
507,  508. 
leave  and,  513. 
in  army,  origin  of,  50.9. 
war  and,  503. 
lectures  on,  682,  683,  684,  685, 

686,  687. 
morbidity,  503. 
Venereological  centres,  676,  677. 
Venous  thrombosis  in  typhoid,  22. 
Vernes  and  Jeanselme,  researches 

of,  556. 
Vertigo  in  syphilis,  586,  633. 
Vibrio,  the  cholera,  399-403. 
agglutination  test  for,  403. 
cultivation  of,  441. 
search  for  and  isolation  of,  400- 

402,  446. 
propagation  of,  413-437. 
races  of,  441. 
Vincent's  angina  in  syphUis,  571, 
583. 
anti-cholera  vaccine,  449. 
spleno-diagnosis  in  typhoid,  106. 
spirillar  infection,  585. 
spirillum,  553. 

vaccine  in  typhoid,  122,  151,  266. 
Viscera,  typhoid  bacilli  in,  177.- 
Visceral  affections  in  syphilis,  585. 

manifestations  in  syphilis,  646. 
Vision  in  typhoid  fever,  65. 


Vomiting  in  cholera,  383. 

in  diarrhcea,  treatment  of,  405. 

in  syphilis,  633. 

in  typhoid  fever,  29,  144. 

War,  and  gastro-intestinal  diseases, 
254. 
and  typhoid  fever,  159,  196. 
flies  as  contagion  carriers  in,  218. 

{See  also  Flies.) 
syphilis  in,  disastrous  influence 
of,  532,  533,  534. 
"War  delirium",  61. 
War  of  Secession,  typhoid  fever  in, 

207. 
Warm  baths  in  tetanus,  888. 
Warships,    prophylactic    measures 

against  cholera  on,  438. 
War-time,  carriers  of  infection  in, 
196. 
mock  vaccinations  in,  291. 
prophylactic  measures  in,  248.  \^ 
Wash,  soap,  667. 
Washes,  mouth,  667. 
Wassermann  Reaction  in  syphilis, 
524,  529,  554,  .555,  556,  562, 
563,  567,  572,  573,  581,  590, 
622. 
and  diagnosis,  554,  555,  556. 
Blumenthal'a   statistics,  of,   554, 
555. 

treatment  and,  651. 
Water,  and  propagation  of  typhoid 
fever,  210. 
distUled,  654. 
dressings,  643. 

importance  of,  in  etiology  of  epi- 
demics, 236. 
in  propagation  of  cholera,  431- 
434,  447. 
of  dysentery,  355-357. 
necessity  of  sterilisation  of,  237, 

247. 
sterilisation  of ,  447.  . 

vitality  of  dysentery  bacilli  in, 
351. 
Wells,  need  of  supervision  of,  237. 
Wet  packs,  134. 

Widal's  serum  test,  details,  47,  118. 
in  non-vaccinator,  118. 
in  vaccinated,  119. 
Wilson's  lichen,  578,  584. 
Women,    contamination    by    their 
husbands  in  syphilis,  521. 
physiological    condition    of,    af- 
fected by  cholera,  396. 


1U2 


INDEX 


Wounds,    local    treatment    of,    in 
tetanus,  846. 
amputations  in,  846. 
antisepsis  in,  847. 

an ti tetanic    serum    in,    dessi- 

cated  and  powdered,  849. 
chemical  agents  in,  847. 
calcium  chloride,  849. 
oxygen,  847. 
tincture  of  iodine,  847. 
physical  agents  in,  849. 
hot  or  cold  air,  849. 
light,  850. 


Yellow  o.Kidc  of  mercury,  60;i. 

Zack,  case  of  cephalic  tetanus,  with 
ophthalmoplegia  with  foot 
as  seat  of  infection,  731. 

Zones,  contaminations  of  Army, 
base  and  rest,  514,  515,  516, 
698,  699. 

Zoerev,  observations  on  vaccina- 
tion against  cholera,  451. 


'(> 


RC971  K43 

Keogh  °°P^  ^ 

Medical  and  surgical  therapy. 


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:i!l::n^lll':ill 


